Provider Demographics
NPI:1104924117
Name:NORTH PARK PHARMACY, INC
Entity type:Organization
Organization Name:NORTH PARK PHARMACY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:CULL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:502-484-3113
Mailing Address - Street 1:327 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OWENTON
Mailing Address - State:KY
Mailing Address - Zip Code:40359-1409
Mailing Address - Country:US
Mailing Address - Phone:502-484-3113
Mailing Address - Fax:502-484-0141
Practice Address - Street 1:327 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OWENTON
Practice Address - State:KY
Practice Address - Zip Code:40359-1409
Practice Address - Country:US
Practice Address - Phone:502-484-3113
Practice Address - Fax:502-484-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPO13633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY54016514Medicaid
KY90020942Medicaid
KY1812848OtherNCPDP NUMBER
KY90020942Medicaid