MEDICARE: MEDICAL PARK PHARMACY WASHINGTON 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
2	3336C0003X	Community/Retail Pharmacy	12066	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2147658	OTHER		PK

General Provider Information

NPI Number	:	1801296116
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL PARK PHARMACY WASHINGTON INC

Provider Business Mailing Address
First Line	:	PO BOX 2308
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-2308
Country	:	US
Telephone Number	:	252-726-0777
Fax Number	:

Provider Business Practice Location Address
First Line	:	1316 JOHN SMALL AVE
Second Line	:
City	:	WASHINGTON
State	:	NC
Zip	:	27889-3843
Country	:	US
Telephone Number	:	252-726-0777
Fax Number	:	252-726-6497

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBERT WILLIAMS
Credential	:
Telephone Number	:	252-726-0777

Provider Enumeration Date	:	08/25/2014
Last Update Date	:	12/18/2016

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