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General NPI Number Information
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NPI Number | 1063465904
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Entity Type | Organization
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Legal Business Name | PARKSIDE PHARMACY INC
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Dates
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Enumeration Date | 05/19/2006
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Last Update Date | 08/15/2016
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Provider Practice Location Address
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Address Line | 2200 FERRY ST
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City | LAFAYETTE
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State | IN
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Zip | 47904-3016
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Country | US
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Telephone | 765-447-1000
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Fax | 765-447-4714
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Provider Business Mailing Address
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Address Line | 2200 FERRY ST
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City | LAFAYETTE
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State | IN
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Zip | 47904-3016
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Country | US
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Telephone | 765-447-1000
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Fax | 765-447-4714
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Authorized Official
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Title or Position | OWNER PHARMACIST
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Name | MR. RANDALL L GERHART
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Credential | BS PHARMACY
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Telephone | 765-447-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number | 60002772A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number | 60002772A
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License Number State | IN
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