1083799373 NPI number — MCCORTNEY DRUG INC

Table of content: (NPI 1083799373)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083799373 NPI number — MCCORTNEY DRUG INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MCCORTNEY DRUG INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MCCORTNEYS FAMILY PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083799373
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 E 9TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74820-3807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-332-3344
Provider Business Mailing Address Fax Number:
580-332-3616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 E 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ADA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74820-3807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-332-3344
Provider Business Practice Location Address Fax Number:
580-332-3616
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
BROCK
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
580-332-3344

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 23-5978 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100238510A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2073507 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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