Provider Demographics
NPI:1295824985
Name:PARK PHARMACY INC
Entity Type:Organization
Organization Name:PARK PHARMACY INC
Other - Org Name:PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GHADA
Authorized Official - Middle Name:
Authorized Official - Last Name:ABDALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-822-0100
Mailing Address - Street 1:15126 KERCHEVAL AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1360
Mailing Address - Country:US
Mailing Address - Phone:313-822-0100
Mailing Address - Fax:313-822-0101
Practice Address - Street 1:15126 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE PARK
Practice Address - State:MI
Practice Address - Zip Code:48230-1360
Practice Address - Country:US
Practice Address - Phone:313-822-0100
Practice Address - Fax:313-822-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336S0011X
MI53010084983336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4998649-87Medicaid
2042400OtherPK
5856950001Medicare NSC