Healthcare Provider Details

I. General information

NPI: 1013958990
Provider Name (Legal Business Name): TCAACP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 05/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 S ASPEN AVE
BROKEN ARROW OK
74012-2296
US

IV. Provider business mailing address

511 S ASPEN AVE
BROKEN ARROW OK
74012-2296
US

V. Phone/Fax

Practice location:
  • Phone: 918-251-6655
  • Fax: 918-251-6622
Mailing address:
  • Phone: 918-251-6655
  • Fax: 918-251-6622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25915
License Number StateOK

VIII. Authorized Official

Name: CALEB MEACHAM
Title or Position: OWNER
Credential: DPH
Phone: 918-251-6655