Provider Demographics
NPI:1447232533
Name:MEDICAL PARK PHARMACY
Entity Type:Organization
Organization Name:MEDICAL PARK PHARMACY
Other - Org Name:MEDICAL PARK UNITED DRUG
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SVENDSEN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:541-672-1800
Mailing Address - Street 1:1813 W HARVARD AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2752
Mailing Address - Country:US
Mailing Address - Phone:541-672-1800
Mailing Address - Fax:541-672-5413
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-2752
Practice Address - Country:US
Practice Address - Phone:541-672-1800
Practice Address - Fax:541-672-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0000490-CS3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005786Medicaid
3804437OtherNCPDP
3804437OtherNCPDP
OR005786Medicaid