Provider Demographics
NPI:1609309913
Name:PARK PHARMACY SCS LLC
Entity Type:Organization
Organization Name:PARK PHARMACY SCS LLC
Other - Org Name:PARK PHARMACY SCS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NASSAR
Authorized Official - Middle Name:
Authorized Official - Last Name:BEYDOUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-999-8560
Mailing Address - Street 1:20225 E 9 MILE RD STE 120A
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1700
Mailing Address - Country:US
Mailing Address - Phone:586-447-5189
Mailing Address - Fax:586-774-7187
Practice Address - Street 1:20225 E 9 MILE RD STE 120A
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080
Practice Address - Country:US
Practice Address - Phone:586-447-5189
Practice Address - Fax:586-774-7187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336S0011X
MI53010111143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2170711OtherPK