Provider Demographics
NPI:1760493340
Name:DAVID N PARK
Entity Type:Organization
Organization Name:DAVID N PARK
Other - Org Name:DBA PARK PLACE PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-475-1775
Mailing Address - Street 1:109 W PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:TN
Mailing Address - Zip Code:38019-2535
Mailing Address - Country:US
Mailing Address - Phone:901-475-1775
Mailing Address - Fax:901-475-6603
Practice Address - Street 1:109 W PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:TN
Practice Address - Zip Code:38019-2535
Practice Address - Country:US
Practice Address - Phone:901-475-1775
Practice Address - Fax:901-475-6603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN43033336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4439647OtherOTHER ID NUMBER-COMMERCIAL NUMBER