MEDICARE: A-CLASS PARK PLACE PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy

General Provider Information

NPI Number	:	1134618648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A-CLASS PARK PLACE PHARMACY LLC

Provider Business Mailing Address
First Line	:	1001 12TH AVE STE 156
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3929
Country	:	US
Telephone Number	:	817-862-9110
Fax Number	:

Provider Business Practice Location Address
First Line	:	1001 12TH AVE STE 156
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3929
Country	:	US
Telephone Number	:	817-862-9110
Fax Number	:

Authorized Official
Title or Position	:	CORPORATE OFFICER
Name	:	SAM SALEH
Credential	:
Telephone Number	:	817-862-9110

Provider Enumeration Date	:	05/09/2018
Last Update Date	:	08/13/2020

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