Provider Demographics
NPI:1902811540
Name:GREENPARK PHARMACY INC
Entity Type:Organization
Organization Name:GREENPARK PHARMACY INC
Other - Org Name:GREEN PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:309-792-1600
Mailing Address - Street 1:PO BOX 50
Mailing Address - Street 2:
Mailing Address - City:COLONA
Mailing Address - State:IL
Mailing Address - Zip Code:61241-0050
Mailing Address - Country:US
Mailing Address - Phone:309-792-1600
Mailing Address - Fax:309-792-1625
Practice Address - Street 1:500 GREEN PARK AVE
Practice Address - Street 2:
Practice Address - City:COLONA
Practice Address - State:IL
Practice Address - Zip Code:61241-9620
Practice Address - Country:US
Practice Address - Phone:309-792-1600
Practice Address - Fax:309-792-1625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0540132763336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2022752OtherPK
IL364094320001Medicaid
IL364094320001Medicaid