MEDICARE: PARC PLAZA 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	3336C0003X	Community/Retail Pharmacy	PENDING	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PENDING	OTHER	TX	PHARMACY LICENSE NUMBER

General Provider Information

NPI Number	:	1720262926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARC PLAZA PHARMACY INC

Provider Business Mailing Address
First Line	:	4801 S BUCKNER BLVD,
Second Line	:	100
City	:	DALLAS
State	:	TX
Zip	:	75227
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4801 S BUCKNER BLVD
Second Line	:	100
City	:	DALLAS
State	:	TX
Zip	:	75227-2373
Country	:	US
Telephone Number	:	214-228-6987
Fax Number	:	214-228-6987

Authorized Official
Title or Position	:	PRESIDENT/ PHARMACIST-IN-CHARGE
Name	:	GLADYS KINYUY NTARYIKE
Credential	:	RPH
Telephone Number	:	214-228-6987

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	12/24/2007

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