MEDICARE: PARK 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	3336C0003X	Community/Retail Pharmacy

General Provider Information

NPI Number	:	1760908636
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK PHARMACY, LLC

Provider Business Mailing Address
First Line	:	710 BROADWAY ST
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63701-5514
Country	:	US
Telephone Number	:	573-335-8207
Fax Number	:	573-335-4904

Provider Business Practice Location Address
First Line	:	37 DOCTORS PARK STE 2
Second Line	:
City	:	CAPE GIRARDEAU
State	:	MO
Zip	:	63703-4903
Country	:	US
Telephone Number	:	573-334-4432
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN WOOD
Credential	:	PHARMD
Telephone Number	:	573-335-8207

Provider Enumeration Date	:	08/22/2017
Last Update Date	:	08/22/2017

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