Provider Demographics
NPI:1972646032
Name:HIGHLAND PARK PHARMACY INC
Entity Type:Organization
Organization Name:HIGHLAND PARK PHARMACY INC
Other - Org Name:HIGHLAND PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:TREADWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-521-2126
Mailing Address - Street 1:3229 KNOX ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4031
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3229 KNOX ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75205-4031
Practice Address - Country:US
Practice Address - Phone:214-521-2126
Practice Address - Fax:214-521-2128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX251793336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
4517477OtherOTHER ID NUMBER
TX143977Medicaid
4517477OtherOTHER ID NUMBER-COMMERCIAL NUMBER