Provider Demographics
NPI:1164598538
Name:MEDPARK PHARMACY
Entity Type:Organization
Organization Name:MEDPARK PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:COLLIER
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:BSP
Authorized Official - Phone:410-573-6900
Mailing Address - Street 1:2002 MEDICAL PKWY
Mailing Address - Street 2:SUITE 170
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3046
Mailing Address - Country:US
Mailing Address - Phone:410-573-6900
Mailing Address - Fax:
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE 170
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3046
Practice Address - Country:US
Practice Address - Phone:410-573-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDP025963336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy