1114974383 NPI number — MEDICAL CENTER PHARMACY OF DURANT INC

Table of content: (NPI 1114974383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114974383 NPI number — MEDICAL CENTER PHARMACY OF DURANT INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CENTER PHARMACY OF DURANT 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:
Provider Other Organization Name Type Code:
6
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:
1114974383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1026 RADIO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURANT
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74701-2991
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-924-2626
Provider Business Mailing Address Fax Number:
580-924-5171

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
908 N ROCKFORD RD
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
ARDMORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73401-2241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-223-6417
Provider Business Practice Location Address Fax Number:
580-223-7376
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEAY
Authorized Official First Name:
GREG
Authorized Official Middle Name:
W
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
580-924-7425

Provider Taxonomy Codes

  • Taxonomy code: 332BX2000X , with the licence number:  12-S-969 , 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: 100234540E , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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