Provider Demographics
NPI:1194162545
Name:WESTPARK DISCOUNT PHARMACY INC
Entity type:Organization
Organization Name:WESTPARK DISCOUNT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT /CEO
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:EGENTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-571-9100
Mailing Address - Street 1:6913 BERNADINE DR
Mailing Address - Street 2:
Mailing Address - City:WATAUGA
Mailing Address - State:TX
Mailing Address - Zip Code:76148-2165
Mailing Address - Country:US
Mailing Address - Phone:817-571-9100
Mailing Address - Fax:817-571-9131
Practice Address - Street 1:5017 HERITAGE AVE STE CON1
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5994
Practice Address - Country:US
Practice Address - Phone:817-571-9100
Practice Address - Fax:817-571-9131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-24
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX285683336C0003X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2140516OtherPK