Basic Information
| Provider Information | |||||||||
| NPI: | 1265804553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | JONG | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHARM.D., BCPS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1479 E EVERGREEN DR | ||||||||
| Address2: | APT 302 | ||||||||
| City: | PALATINE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600748750 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 W MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | MCHENRY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600508409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157594400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2015 | ||||||||
| LastUpdateDate: | 10/26/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1835P1200X | 051291746 | IL | Y | Pharmacy Service Providers | Pharmacist | Pharmacotherapy |
No ID Information.