Provider Demographics
NPI:1699888719
Name:PARKER PROFESSIONAL PHARMACY
Entity type:Organization
Organization Name:PARKER PROFESSIONAL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:CALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:303-840-6424
Mailing Address - Street 1:10371 S PARK GLENN WAY
Mailing Address - Street 2:#170
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80138-3869
Mailing Address - Country:US
Mailing Address - Phone:303-840-3454
Mailing Address - Fax:303-840-5364
Practice Address - Street 1:10371 S PARK GLENN WAY
Practice Address - Street 2:#170
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80138-3869
Practice Address - Country:US
Practice Address - Phone:303-840-3454
Practice Address - Fax:303-840-5364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO10800000103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO03003837Medicaid