Healthcare Provider Details

I. General information

NPI: 1770127250
Provider Name (Legal Business Name): MP SOUTHPARK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 03/11/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E SAN SABA ST
MENARD TX
76859-2709
US

IV. Provider business mailing address

1804 HALL AVE
LITTLEFIELD TX
79339-5439
US

V. Phone/Fax

Practice location:
  • Phone: 325-396-2480
  • Fax:
Mailing address:
  • Phone: 325-655-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER D WHITE
Title or Position: FINANCE MANAGER
Credential:
Phone: 325-655-3146