Provider Demographics
NPI:1831587963
Name:PARK SPECIALTY COMPOUNDING PHARMACY PLLC
Entity type:Organization
Organization Name:PARK SPECIALTY COMPOUNDING PHARMACY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:AMEE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:BS IN PHARMACY
Authorized Official - Phone:832-347-2516
Mailing Address - Street 1:23510 KINGSLAND BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494
Mailing Address - Country:US
Mailing Address - Phone:281-665-8899
Mailing Address - Fax:281-665-8897
Practice Address - Street 1:23510 KINGSLAND BLVD STE 104
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-4126
Practice Address - Country:US
Practice Address - Phone:281-665-8899
Practice Address - Fax:281-665-8897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-23
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 332B00000X, 3336S0011X
TX297143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149446OtherPK
TX147048Medicaid