MEDICARE: FOUNTAIN PARK PHARMACY INC.

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	PHY007141IR	LA
2	333600000X	Pharmacy	LA1845	KY
3	3336C0003X	Community/Retail Pharmacy	PH27207	FL
4	333600000X	Pharmacy	5277	TN
5	3336C0004X	Compounding Pharmacy	PHNR000702	GA
6	333600000X	Pharmacy	14022/7.1	MS
7	333600000X	Pharmacy	15677	SC
8	333600000X	Pharmacy	22-44626	KS
9	333600000X	Pharmacy	114250	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2142276	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407282585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN PARK PHARMACY INC.

Provider Business Mailing Address
First Line	:	1901 MANHATTAN BLVD
Second Line	:	BUILDING F SUITE 104
City	:	HARVEY
State	:	LA
Zip	:	70058-3582
Country	:	US
Telephone Number	:	504-434-4777
Fax Number	:	504-309-8031

Provider Business Practice Location Address
First Line	:	1901 MANHATTAN BLVD
Second Line	:	BUILDING F SUITE 104
City	:	HARVEY
State	:	LA
Zip	:	70058-3582
Country	:	US
Telephone Number	:	504-434-4777
Fax Number	:	504-309-8031

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	JO STEPHANIE CULOTTA
Credential	:	PHARMACIST
Telephone Number	:	504-434-4777

Provider Enumeration Date	:	09/19/2013
Last Update Date	:	09/01/2016

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