Healthcare Provider Details

I. General information

NPI: 1083777601
Provider Name (Legal Business Name): THE APOTHECARY SHOPPE OF BA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N ELM PL
BROKEN ARROW OK
74012-2539
US

IV. Provider business mailing address

6136 E 51ST ST
TULSA OK
74135-7704
US

V. Phone/Fax

Practice location:
  • Phone: 918-449-9988
  • Fax: 918-449-9989
Mailing address:
  • Phone: 918-665-2003
  • Fax: 918-665-8283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-6501
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: THOMAS MARTI
Title or Position: PRESIDENT
Credential: PHARMD
Phone: 918-665-2003