MEDICARE: SCOTTS PHARMACY LLC

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
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	4-6086	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2124412	OTHER		PK

General Provider Information

NPI Number	:	1891898912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SCOTTS PHARMACY LLC

Provider Business Mailing Address
First Line	:	PO BOX 967
Second Line	:
City	:	FORT GIBSON
State	:	OK
Zip	:	74434-0967
Country	:	US
Telephone Number	:	918-478-3002
Fax Number	:	918-478-3017

Provider Business Practice Location Address
First Line	:	1201 S LEE ST
Second Line	:
City	:	FORT GIBSON
State	:	OK
Zip	:	74434
Country	:	US
Telephone Number	:	918-478-3002
Fax Number	:	918-478-3017

Authorized Official
Title or Position	:	OWNER
Name	:	JUSTIN BLAKE WILSON
Credential	:
Telephone Number	:	405-741-1200

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	11/10/2021

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Directions to “SCOTTS PHARMACY LLC ” Practice Location

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