Provider Demographics
NPI:1770775694
Name:PARK, CHRISTINA BOHYOUNG
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:BOHYOUNG
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 1:3545 WILSHIRE BLVD
Mailing Address - Street 2:#200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2354
Mailing Address - Country:US
Mailing Address - Phone:213-385-2135
Mailing Address - Fax:
Practice Address - Street 1:3545 WILSHIRE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2378
Practice Address - Country:US
Practice Address - Phone:213-385-2135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-14
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH59128183500000X
NV15301183500000X
HIPH-1829183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6414260001Medicare NSC