Provider Demographics
NPI:1215058797
Name:PARKS PHARMACY INC
Entity type:Organization
Organization Name:PARKS PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-799-1489
Mailing Address - Street 1:PO BOX 250310
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36125-0310
Mailing Address - Country:US
Mailing Address - Phone:334-548-6240
Mailing Address - Fax:334-548-6246
Practice Address - Street 1:225 HAYNEVILLE PLZ
Practice Address - Street 2:
Practice Address - City:HAYNEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36040-2669
Practice Address - Country:US
Practice Address - Phone:334-548-6240
Practice Address - Fax:334-323-5663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
AL1128163336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
0132364OtherNCPDP PROVIDER IDENTIFICATION NUMBER
AL100003543Medicaid
AL100003578Medicaid