Provider Demographics
NPI:1689677999
Name:PARK PHARMACY INC
Entity Type:Organization
Organization Name:PARK PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PECHACEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-762-3248
Mailing Address - Street 1:138 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PARK FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54552-1214
Mailing Address - Country:US
Mailing Address - Phone:715-762-3248
Mailing Address - Fax:715-762-2980
Practice Address - Street 1:138 2ND AVE N
Practice Address - Street 2:
Practice Address - City:PARK FALLS
Practice Address - State:WI
Practice Address - Zip Code:54552-1214
Practice Address - Country:US
Practice Address - Phone:715-762-3248
Practice Address - Fax:715-762-2980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-31
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7644-042333600000X
WI7643-0423336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33219200Medicaid
1226000001Medicare NSC