Provider Demographics
NPI:1982855763
Name:FIRST PHARMACY SERVICES OF PARK AVE INC
Entity Type:Organization
Organization Name:FIRST PHARMACY SERVICES OF PARK AVE INC
Other - Org Name:FIRST PHARMACY SERVICES OF PARK AVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-821-8330
Mailing Address - Street 1:PO BOX 47
Mailing Address - Street 2:
Mailing Address - City:POPE
Mailing Address - State:MS
Mailing Address - Zip Code:38658
Mailing Address - Country:US
Mailing Address - Phone:901-946-1375
Mailing Address - Fax:
Practice Address - Street 1:6005 PARK AVE STE 630B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5226
Practice Address - Country:US
Practice Address - Phone:901-821-8330
Practice Address - Fax:901-821-8350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-10
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0002X, 3336L0003X
TN45713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117378OtherPK