Provider Demographics
NPI:1730739152
Name:PARK, GRACE HYEYOUNG
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:HYEYOUNG
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8323 N SHANNON RD UNIT 15103
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85742-6120
Mailing Address - Country:US
Mailing Address - Phone:918-884-8138
Mailing Address - Fax:
Practice Address - Street 1:1625 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85719-4330
Practice Address - Country:US
Practice Address - Phone:520-694-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17707183500000X
AZS023552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist