MEDICARE: JERRYS PHARMACY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy	502796	OK
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3713179	OTHER		OTHER ID NUMBER-COMMERCIAL NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639262074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRYS PHARMACY

Provider Business Mailing Address
First Line	:	1549 MAIN ST
Second Line	:
City	:	WAYNOKA
State	:	OK
Zip	:	73860-2008
Country	:	US
Telephone Number	:	580-824-1741
Fax Number	:	580-824-2172

Provider Business Practice Location Address
First Line	:	1549 MAIN ST
Second Line	:
City	:	WAYNOKA
State	:	OK
Zip	:	73860-2008
Country	:	US
Telephone Number	:	580-824-1741
Fax Number	:	580-824-2172

Authorized Official
Title or Position	:	OWNER
Name	:	JERRY DENNIS
Credential	:
Telephone Number	:	580-824-1741

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	06/17/2008

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Directions to “JERRYS PHARMACY ” Practice Location

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