1336185222 NPI number — COLLINSVILLE FAMILY PHARMACY LC

Table of content: (NPI 1336185222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336185222 NPI number — COLLINSVILLE FAMILY PHARMACY LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COLLINSVILLE FAMILY PHARMACY LC
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:
COLLINSVILLE 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:
1336185222
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1205 W MAIN ST STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLLINSVILLE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74021-3114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-371-2547
Provider Business Mailing Address Fax Number:
918-371-0268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1205 W MAIN ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLINSVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74021-3114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-371-2547
Provider Business Practice Location Address Fax Number:
918-371-0268
Provider Enumeration Date:
06/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TURNBULL
Authorized Official First Name:
COLTON
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PHARMACIST AND OWNER
Authorized Official Telephone Number:
918-371-2547

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 26388 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2081529 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100807920B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100807920A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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