Healthcare Provider Details

I. General information

NPI: 1043393093
Provider Name (Legal Business Name): PHILLIP W & PHYLLIS J MELTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 E EVANS
APACHE OK
73006-9802
US

IV. Provider business mailing address

PO BOX 315
APACHE OK
73006-0315
US

V. Phone/Fax

Practice location:
  • Phone: 580-588-3639
  • Fax: 580-588-3638
Mailing address:
  • Phone: 580-588-3639
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number203327
License Number StateOK

VIII. Authorized Official

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