Provider Demographics
NPI:1366541229
Name:MEDICAL PARK PHARMACY INC
Entity type:Organization
Organization Name:MEDICAL PARK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:VANMETER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:276-935-6455
Mailing Address - Street 1:1503 SLATE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-6974
Mailing Address - Country:US
Mailing Address - Phone:276-935-6455
Mailing Address - Fax:276-935-2981
Practice Address - Street 1:1503 SLATE CREEK RD
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6974
Practice Address - Country:US
Practice Address - Phone:276-935-6455
Practice Address - Fax:276-935-2981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
VA02010022983336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2104298OtherPK
KY54019989Medicaid
WV0144027000Medicaid
VA8515476Medicaid
VA0760220001Medicare NSC