Provider Demographics
NPI:1881976876
Name:PARK, SOPHIA YOONJUNG (PHARMD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:YOONJUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:SAN FIDEL
Mailing Address - State:NM
Mailing Address - Zip Code:87049-0130
Mailing Address - Country:US
Mailing Address - Phone:505-552-5394
Mailing Address - Fax:
Practice Address - Street 1:80B VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:ACOMA
Practice Address - State:NM
Practice Address - Zip Code:87034
Practice Address - Country:US
Practice Address - Phone:505-552-5394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD197661835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist