=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699888719
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARKER PROFESSIONAL PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2006
-----------------------------------------------------
Last Update Date | 01/26/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10371 S PARK GLENN WAY #170
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80138-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-840-3454
-----------------------------------------------------
Fax | 303-840-5364
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10371 S PARK GLENN WAY #170
-----------------------------------------------------
City | PARKER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80138-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-840-3454
-----------------------------------------------------
Fax | 303-840-5364
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | MR. STANLEY GEORGE CALLAS
-----------------------------------------------------
Credential | RPH
-----------------------------------------------------
Telephone | 303-840-6424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 1080000010
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------