Provider Demographics
NPI:1558324624
Name:MEDICAL PARK PHARMACY LLC
Entity Type:Organization
Organization Name:MEDICAL PARK PHARMACY 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:VADA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:479-253-9751
Mailing Address - Street 1:121 E. VANBUREN
Mailing Address - Street 2:SUITE C
Mailing Address - City:EUREKA SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72632
Mailing Address - Country:US
Mailing Address - Phone:479-253-9751
Mailing Address - Fax:479-253-7149
Practice Address - Street 1:121 E VAN BUREN STE C
Practice Address - Street 2:
Practice Address - City:EUREKA SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72632-3658
Practice Address - Country:US
Practice Address - Phone:479-253-9751
Practice Address - Fax:479-253-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
ARAR202643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO605854900Medicaid
1992914OtherPK
AR142172407Medicaid
1992914OtherPK