Provider Demographics
NPI:1114932753
Name:SOUTH SCRIPT HEALTH CARE INC
Entity Type:Organization
Organization Name:SOUTH SCRIPT HEALTH CARE INC
Other - Org Name:PARK PLACE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:817-924-9292
Mailing Address - Street 1:1601 PARK PLACE AVE
Mailing Address - Street 2:STE B
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1303
Mailing Address - Country:US
Mailing Address - Phone:817-924-9292
Mailing Address - Fax:817-924-9264
Practice Address - Street 1:1601 PARK PLACE AVE
Practice Address - Street 2:STE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76110-1303
Practice Address - Country:US
Practice Address - Phone:817-924-9292
Practice Address - Fax:817-924-9264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX239883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2096886OtherPK
TX145526Medicaid
TX145526Medicaid