Provider Demographics
NPI:1861564437
Name:MEDICAL PARK PHARMACY OF GREAT BEND PA
Entity type:Organization
Organization Name:MEDICAL PARK PHARMACY OF GREAT BEND PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPH PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:LAVERN
Authorized Official - Last Name:REGIER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:620-792-1221
Mailing Address - Street 1:1309 POLK
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3644
Mailing Address - Country:US
Mailing Address - Phone:620-792-1221
Mailing Address - Fax:620-792-6413
Practice Address - Street 1:1309 POLK
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3644
Practice Address - Country:US
Practice Address - Phone:620-792-1221
Practice Address - Fax:620-792-6413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100444470AMedicaid
KS100444470BMedicaid
KS100444470BMedicaid
KS1710474Medicare UPIN