Healthcare Provider Details

I. General information

NPI: 1134787435
Provider Name (Legal Business Name): CATOOSA PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 N HIGHWAY 66 STE A
CATOOSA OK
74015-3052
US

IV. Provider business mailing address

13405 E 91ST ST N
OWASSO OK
74055-2657
US

V. Phone/Fax

Practice location:
  • Phone: 918-739-4774
  • Fax: 918-739-4778
Mailing address:
  • Phone: 918-231-9034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 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: DAVID KENT JOHNSON
Title or Position: MANAGING MEMBER
Credential: PHARMD
Phone: 918-231-9034