Provider Demographics
NPI:1720224702
Name:MEDICAL PARK PHARMACY GREENVILLE, INC
Entity Type:Organization
Organization Name:MEDICAL PARK PHARMACY GREENVILLE, INC
Other - Org Name:MEDICAL PARK PHARMACY SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-726-0777
Mailing Address - Street 1:4814 OLD TAR RD
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7852
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4814 OLD TAR RD
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-7852
Practice Address - Country:US
Practice Address - Phone:252-752-8800
Practice Address - Fax:252-752-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-23
Last Update Date:2009-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3413224OtherNCPDP PROVIDER IDENTIFICATION NUMBER