Provider Demographics
NPI:1114917903
Name:PARKLAND APOTHECARY LLC
Entity Type:Organization
Organization Name:PARKLAND APOTHECARY LLC
Other - Org Name:PARKLAND HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:UMFLEET
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:573-431-6677
Mailing Address - Street 1:1131 N DESLOGE DR
Mailing Address - Street 2:
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-2936
Mailing Address - Country:US
Mailing Address - Phone:573-431-6677
Mailing Address - Fax:573-431-3833
Practice Address - Street 1:1131 N DESLOGE DR
Practice Address - Street 2:
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-2936
Practice Address - Country:US
Practice Address - Phone:573-431-6677
Practice Address - Fax:573-431-3833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336S0011X
MO20050285383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2049127OtherPK
MO606222008Medicaid
5569590001Medicare NSC