Provider Demographics
NPI:1982726279
Name:L PARK LLC
Entity Type:Organization
Organization Name:L PARK LLC
Other - Org Name:GILMORE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PIC
Authorized Official - Prefix:
Authorized Official - First Name:ILEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMINGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RPHD
Authorized Official - Phone:201-868-5005
Mailing Address - Street 1:6000 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093
Mailing Address - Country:US
Mailing Address - Phone:201-868-5005
Mailing Address - Fax:201-868-5974
Practice Address - Street 1:6000 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093
Practice Address - Country:US
Practice Address - Phone:201-868-5005
Practice Address - Fax:201-868-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ3201333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3123786OtherNCPDP
NJ0547361Medicaid