Provider Demographics
NPI:1104022516
Name:PARK PHARMACY, INC
Entity Type:Organization
Organization Name:PARK PHARMACY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:864-456-7411
Mailing Address - Street 1:9 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARE SHOALS
Mailing Address - State:SC
Mailing Address - Zip Code:29692-1301
Mailing Address - Country:US
Mailing Address - Phone:864-456-7411
Mailing Address - Fax:864-456-3026
Practice Address - Street 1:9 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WARE SHOALS
Practice Address - State:SC
Practice Address - Zip Code:29692-1301
Practice Address - Country:US
Practice Address - Phone:864-456-7411
Practice Address - Fax:864-456-3026
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC715701Medicaid
SC715701Medicaid