Healthcare Provider Details

I. General information

NPI: 1427141860
Provider Name (Legal Business Name): PHILLIP W & PHYLLIS J MELTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 E CENTRAL BLVD SUITE 1
ANADARKO OK
73005-4406
US

IV. Provider business mailing address

1104 E CENTRAL BLVD SUITE 1
ANADARKO OK
73005-4406
US

V. Phone/Fax

Practice location:
  • Phone: 405-247-3081
  • Fax: 405-247-3081
Mailing address:
  • Phone: 405-247-3081
  • Fax: 405-247-3081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20-4065
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PHILIP MELTON
Title or Position: OWNER
Credential: RPH
Phone: 405-247-3081