Provider Demographics
NPI:1629448089
Name:PARK MEDICAL RX LLC
Entity Type:Organization
Organization Name:PARK MEDICAL RX LLC
Other - Org Name:PARK MEDICAL RX LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MAITHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:ALSHARIFI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-930-2185
Mailing Address - Street 1:20720 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1275
Mailing Address - Country:US
Mailing Address - Phone:313-651-5887
Mailing Address - Fax:313-651-5889
Practice Address - Street 1:20720 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1275
Practice Address - Country:US
Practice Address - Phone:313-651-5887
Practice Address - Fax:313-651-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010107273336C0003X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154994OtherPK
2154994OtherPK