Healthcare Provider Details

I. General information

NPI: 1427081447
Provider Name (Legal Business Name): MP SOUTHPARK PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/12/2025
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 S CHADB0URNE
SAN ANGELO TX
76903-5891
US

IV. Provider business mailing address

29 S CHADB0URNE
SAN ANGELO TX
76903-5891
US

V. Phone/Fax

Practice location:
  • Phone: 325-655-3146
  • Fax: 325-658-5891
Mailing address:
  • Phone: 325-655-3146
  • Fax: 325-658-5891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31522
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICAH PRATT
Title or Position: OWNER
Credential: PHARMD
Phone: 806-548-0590