1942366430 NPI number — 1ST PHARMACY CORP

Table of content: (NPI 1942366430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942366430 NPI number — 1ST PHARMACY CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
1ST PHARMACY CORP
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:
DBA: LAWTON 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:
1942366430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2702 W. GORE BLVD.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-353-0760
Provider Business Mailing Address Fax Number:
580-353-1411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2702 W. GORE BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-353-0760
Provider Business Practice Location Address Fax Number:
580-353-1411
Provider Enumeration Date:
12/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NALL
Authorized Official First Name:
JANIS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
940-648-2222

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  34605 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100241550A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3705653 . This is a "NABP" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 34605 . This is a "OKLAHOMA PHARMACY LICENSE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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