Provider Demographics
NPI:1134618648
Name:A-CLASS PARK PLACE PHARMACY LLC
Entity type:Organization
Organization Name:A-CLASS PARK PLACE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:SALEH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-862-9110
Mailing Address - Street 1:1001 12TH AVE STE 156
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3929
Mailing Address - Country:US
Mailing Address - Phone:817-862-9110
Mailing Address - Fax:
Practice Address - Street 1:1001 12TH AVE STE 156
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3929
Practice Address - Country:US
Practice Address - Phone:817-862-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-09
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy