1356724157 NPI number — MARIETTA PHARMACY LLC

Table of content: (NPI 1356724157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356724157 NPI number — MARIETTA PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIETTA PHARMACY LLC
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:
MARIETTA 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:
1356724157
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
744 S MISSISSIPPI AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATOKA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74525-3355
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-276-5555
Provider Business Mailing Address Fax Number:
580-276-5355

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 S HIGHWAY 77
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73448-3447
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-276-5555
Provider Business Practice Location Address Fax Number:
580-276-5355
Provider Enumeration Date:
06/30/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RITTER
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
580-889-3353

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: 72-7286 , 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: 100235740B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2152842 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100235740C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".