Provider Demographics
NPI:1306827985
Name:PARKS DRUG STORE INC
Entity Type:Organization
Organization Name:PARKS DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHEDD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:517-629-9481
Mailing Address - Street 1:318 S SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224
Mailing Address - Country:US
Mailing Address - Phone:517-629-9481
Mailing Address - Fax:517-629-8904
Practice Address - Street 1:318 S SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:MI
Practice Address - Zip Code:49224
Practice Address - Country:US
Practice Address - Phone:517-629-9481
Practice Address - Fax:517-629-8904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020827183500000X, 332B00000X
MI5301001976183500000X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes333600000XSuppliersPharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2513829Medicaid
MI540A30523OtherBCBSM
MI0136150001Medicare NSC