Provider Demographics
NPI:1477891513
Name:MEDICAL PARK PHARMACY GREENVILLE, INC
Entity Type:Organization
Organization Name:MEDICAL PARK PHARMACY GREENVILLE, INC
Other - Org Name:MEDICAL PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:WICHER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-321-0222
Mailing Address - Street 1:1872 W ARLINGTON BLVD
Mailing Address - Street 2:SUITE M
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5704
Mailing Address - Country:US
Mailing Address - Phone:252-321-0222
Mailing Address - Fax:252-321-0508
Practice Address - Street 1:1872 W ARLINGTON BLVD
Practice Address - Street 2:SUITE M
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5704
Practice Address - Country:US
Practice Address - Phone:252-321-0222
Practice Address - Fax:252-321-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-24
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11060333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0745961Medicaid
NC7704562Medicaid
NC5761370001Medicare NSC