Provider Demographics
NPI:1588672562
Name:PARK MEDICAL PHARMACY
Entity Type:Organization
Organization Name:PARK MEDICAL PHARMACY
Other - Org Name:MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-262-4373
Mailing Address - Street 1:610 GATEWAY CENTER WAY
Mailing Address - Street 2:STE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4533
Mailing Address - Country:US
Mailing Address - Phone:619-238-9501
Mailing Address - Fax:619-398-2929
Practice Address - Street 1:610 GATEWAY CENTER WAY
Practice Address - Street 2:STE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4533
Practice Address - Country:US
Practice Address - Phone:619-238-9501
Practice Address - Fax:619-398-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH46224183500000X
CAPHY44338183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA443380Medicaid
CAPHY44338OtherPHARMACY LICENSE
CABM6549142OtherPHARMACY DEA
CA0225250001Medicare ID - Type Unspecified