Provider Demographics
NPI:1760888390
Name:PARKVILLE PHARMACY LLC
Entity Type:Organization
Organization Name:PARKVILLE PHARMACY LLC
Other - Org Name:PARKVILLE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KISHOR
Authorized Official - Middle Name:
Authorized Official - Last Name:BUPATHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-290-4867
Mailing Address - Street 1:8118 HARFORD RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-5725
Mailing Address - Country:US
Mailing Address - Phone:443-290-4867
Mailing Address - Fax:443-290-4868
Practice Address - Street 1:8118 HARFORD RD
Practice Address - Street 2:STE B
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234-5725
Practice Address - Country:US
Practice Address - Phone:443-290-4867
Practice Address - Fax:443-290-4868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MDP064863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0862215Medicaid
2148556OtherPK