Provider Demographics
NPI:1174626436
Name:PARK, JOE BUCK (R PH)
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:BUCK
Last Name:PARK
Suffix:
Gender:M
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 HUNTINGTON DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2810
Mailing Address - Country:US
Mailing Address - Phone:972-234-1920
Mailing Address - Fax:214-363-6570
Practice Address - Street 1:515 PRESTON ROYAL VILLAGE
Practice Address - Street 2:DOUGHERTY'S PHARMACY INC.
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230
Practice Address - Country:US
Practice Address - Phone:214-363-4318
Practice Address - Fax:214-363-6570
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX15052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX15052OtherPHARMACIST LICENSE