Provider Demographics
NPI:1588987051
Name:MEDICAL PARK PHARMACY LTC INC
Entity type:Organization
Organization Name:MEDICAL PARK PHARMACY LTC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-654-2277
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:LAVALETTE
Mailing Address - State:WV
Mailing Address - Zip Code:25535-0999
Mailing Address - Country:US
Mailing Address - Phone:304-654-2277
Mailing Address - Fax:
Practice Address - Street 1:4118 5TH STREET RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-9547
Practice Address - Country:US
Practice Address - Phone:304-529-3784
Practice Address - Fax:304-529-3785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2016-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSP05524063336L0003X
OHNRP022419250-033336L0003X
KYWV19383336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124436OtherPK