Provider Demographics
NPI:1619385812
Name:PARK PHARMACY LLC
Entity Type:Organization
Organization Name:PARK PHARMACY LLC
Other - Org Name:PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIMEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-806-9000
Mailing Address - Street 1:4811 AMBASSADOR CAFFERY PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-7266
Mailing Address - Country:US
Mailing Address - Phone:337-806-9000
Mailing Address - Fax:337-806-9074
Practice Address - Street 1:4811 AMBASSADOR CAFFERY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-7266
Practice Address - Country:US
Practice Address - Phone:337-806-9000
Practice Address - Fax:337-806-9074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-31
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
LAPHY006937IR3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2202910Medicaid
2147229OtherPK