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Provider Information for 1922135763


The following NPI(s) contain information matching your search criteria. Please select the NPI to view all the data associated with the NPI.

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SOUTH PARK PHARMACY LLC

Other Names:  
Doing Business As: 
SOUTH PARK PHARMACY

Organization Subpart: NO

NPI: 1922135763
Last Updated: 2017-04-21
Certification Date:

Details

NameValue
NPI1922135763
Enumeration Date2007-02-28
NPI TypeNPI-2 Organization
StatusActive
Authorized Official Information Name: SHAWN SHELTON RPH
Title: Owner/PIC/AO
Phone: 7168230440
Mailing Address 2707 S PARK AVE
LACKAWANNA, NY 14218-1511
United States

Phone: 716-823-0440 | Fax:716-823-0444
 
Primary Practice Address 2707 S PARK AVE
LACKAWANNA, NY 14218-1511
United States

Phone: 716-823-0440 | Fax:716-823-0444
 
Secondary Practice Address(es)
Health Information Exchange
Endpoint TypeEndpointEndpoint DescriptionUseContent TypeAffiliationEndpoint Location
Other Identifiers
IssuerStateNumberOther Issuer
MEDICAIDNY02885981
Other (non-Medicare)2068947PK
Taxonomy
Primary TaxonomySelected TaxonomyStateLicense Number
No 333600000X - Pharmacy
No 332B00000X - Durable Medical Equipment & Medical Supplies
Yes 3336C0003X - Pharmacy - Community/Retail PharmacyNY028253