Organization
SOUTH PARK PHARMACY LLC
Active
Other names
SOUTH PARK PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
SHAWN SHELTON RPH (OWNER/PIC/AO)
(716) 823-0440
Entity
Organization
Contact information
Practice address
2707 S PARK AVE, LACKAWANNA, NY 14218-1511
(716) 823-0440
(716) 823-0444
Mailing address
2707 S PARK AVE, LACKAWANNA, NY 14218-1511
(716) 823-0440
(716) 823-0444
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
028253
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02885981
—
NY
01
—
2068947
PK
—
Enumeration date
02/28/2007
Last updated
04/21/2017
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