Provider Demographics
NPI:1497869481
Name:KCN NOVAK LLC
Entity Type:Organization
Organization Name:KCN NOVAK LLC
Other - Org Name:MEDICAL PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:NOVAK
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:903-234-8326
Mailing Address - Street 1:615 N 3RD ST
Mailing Address - Street 2:SUITE # 1
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6550
Mailing Address - Country:US
Mailing Address - Phone:903-234-8329
Mailing Address - Fax:903-247-9513
Practice Address - Street 1:709 HOLLYBROOK DR
Practice Address - Street 2:STE 101
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2411
Practice Address - Country:US
Practice Address - Phone:903-234-8326
Practice Address - Fax:903-758-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X
TX159603336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144123Medicaid
2104156OtherPK
2104156OtherPK