Provider Demographics
NPI:1437256278
Name:SOUTH PARK REXALL PHARMACY, INC.
Entity Type:Organization
Organization Name:SOUTH PARK REXALL PHARMACY, INC.
Other - Org Name:SOUTH PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:PASKETT
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:360-871-1020
Mailing Address - Street 1:1743 VILLAGE LN SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2643
Mailing Address - Country:US
Mailing Address - Phone:360-871-1020
Mailing Address - Fax:360-871-1213
Practice Address - Street 1:1743 VILLAGE LN SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2643
Practice Address - Country:US
Practice Address - Phone:360-871-1020
Practice Address - Fax:360-871-1213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WAPHARCF000008043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6174205Medicaid
4911649OtherNCPDP PROVIDER IDENTIFICATION NUMBER
4911649OtherNCPDP PROVIDER IDENTIFICATION NUMBER