Provider Demographics
NPI:1649642422
Name:MEDICAL PARK PHARMACY EAST, INC
Entity type:Organization
Organization Name:MEDICAL PARK PHARMACY EAST, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:252-241-6010
Mailing Address - Street 1:1513 LIVE OAK ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:NC
Mailing Address - Zip Code:28516-1518
Mailing Address - Country:US
Mailing Address - Phone:252-504-2800
Mailing Address - Fax:252-504-2805
Practice Address - Street 1:1513 LIVE OAK ST
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:NC
Practice Address - Zip Code:28516-1518
Practice Address - Country:US
Practice Address - Phone:252-504-2800
Practice Address - Fax:252-504-2805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC091823336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0165449Medicaid
NC0165449Medicaid