Provider Demographics
NPI:1669779435
Name:PARK MEDICAL PHARMACY
Entity type:Organization
Organization Name:PARK MEDICAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:619-997-4702
Mailing Address - Street 1:750 MEDICAL CENTER CT
Mailing Address - Street 2:STE 1
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-6634
Mailing Address - Country:US
Mailing Address - Phone:619-421-1131
Mailing Address - Fax:619-421-7405
Practice Address - Street 1:750 MEDICAL CENTER CT
Practice Address - Street 2:STE 1
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-6634
Practice Address - Country:US
Practice Address - Phone:619-421-1131
Practice Address - Fax:619-421-7405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
CAPHY505783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2128995OtherPK