Provider Demographics
NPI:1073618302
Name:MEDI-PARK PHARMACY
Entity Type:Organization
Organization Name:MEDI-PARK PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:RAYMOND
Authorized Official - Last Name:PANDOLFI
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:806-359-5496
Mailing Address - Street 1:1920 MEDI PARK DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-2104
Mailing Address - Country:US
Mailing Address - Phone:806-359-5496
Mailing Address - Fax:806-355-9533
Practice Address - Street 1:1920 MEDI PARK DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2104
Practice Address - Country:US
Practice Address - Phone:806-359-5496
Practice Address - Fax:806-355-9533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX145753336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX143815Medicaid
4551669OtherNABP
4551669OtherNABP