Provider Demographics
NPI:1306912472
Name:MEDICAL PARK TOWER PHARMACY
Entity type:Organization
Organization Name:MEDICAL PARK TOWER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-454-5626
Mailing Address - Street 1:1301 W 38TH ST
Mailing Address - Street 2:STE. 135
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1000
Mailing Address - Country:US
Mailing Address - Phone:512-454-5626
Mailing Address - Fax:512-454-3939
Practice Address - Street 1:1301 W 38TH ST
Practice Address - Street 2:STE. 135
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1000
Practice Address - Country:US
Practice Address - Phone:512-454-5626
Practice Address - Fax:512-454-3939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18915183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144753Medicaid