Provider Demographics
NPI:1639165160
Name:PROFESSIONAL PRESCRIPTION SERVICES LLC
Entity Type:Organization
Organization Name:PROFESSIONAL PRESCRIPTION SERVICES LLC
Other - Org Name:PARKLAND HEALTH MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:RADEMAKER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:636-933-2224
Mailing Address - Street 1:1131 N DESLOGE DR
Mailing Address - Street 2:
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-2936
Mailing Address - Country:US
Mailing Address - Phone:573-431-6677
Mailing Address - Fax:573-431-3833
Practice Address - Street 1:348 FESTUS CENTRE DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2458
Practice Address - Country:US
Practice Address - Phone:636-933-2224
Practice Address - Fax:636-933-2264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-20
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MO20040290453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO606159507Medicaid
2049048OtherPK
5306210001Medicare NSC