Provider Demographics
NPI:1477990117
Name:PARK SPECIALTY SERVICES LLC
Entity Type:Organization
Organization Name:PARK SPECIALTY SERVICES LLC
Other - Org Name:CHAMPAIGN FAMILY 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:313-622-7465
Mailing Address - Street 1:14726 CHAMPAIGN RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1617
Mailing Address - Country:US
Mailing Address - Phone:313-382-0000
Mailing Address - Fax:313-382-0002
Practice Address - Street 1:14726 CHAMPAIGN RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-1617
Practice Address - Country:US
Practice Address - Phone:313-382-0000
Practice Address - Fax:313-382-0002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-03
Last Update Date:2013-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315062632333600000X
MI53010101703336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy