Provider Information for 1922135763
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SOUTH PARK PHARMACY LLC
Other Names:Doing Business As:SOUTH PARK PHARMACYOrganization Subpart: NO
NPI: 1922135763
Last Updated: 2017-04-21
Certification Date:
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Details
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NPI | 1922135763 | ||||||||||||||||
Enumeration Date | 2007-02-28 | ||||||||||||||||
NPI Type | NPI-2 Organization | ||||||||||||||||
Status | Active | ||||||||||||||||
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 | ||||||||||||||||
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