Provider Demographics
NPI:1558602714
Name:MACHIAS FRIENDLY PHARMACY
Entity Type:Organization
Organization Name:MACHIAS FRIENDLY PHARMACY
Other - Org Name:SOUTHPARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PRINCE
Authorized Official - Middle Name:
Authorized Official - Last Name:OGBONNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-353-6530
Mailing Address - Street 1:3324 S GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-3446
Mailing Address - Country:US
Mailing Address - Phone:806-353-6530
Mailing Address - Fax:806-353-6535
Practice Address - Street 1:3324 S GEORGIA ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-3446
Practice Address - Country:US
Practice Address - Phone:806-353-6530
Practice Address - Fax:806-353-6535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-12
Last Update Date:2013-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
TX285993336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139385OtherPK