Healthcare Provider Details

I. General information

NPI: 1629377064
Provider Name (Legal Business Name): CENTRAL DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 N MAIN ST
CEMENT OK
73017-0300
US

IV. Provider business mailing address

PO BOX 300
CEMENT OK
73017-0300
US

V. Phone/Fax

Practice location:
  • Phone: 405-489-3521
  • Fax: 405-489-3521
Mailing address:
  • Phone: 405-489-3521
  • Fax: 405-489-3521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number20-5654
License Number StateOK

VIII. Authorized Official

Name: GLENN GILBREATH JR.
Title or Position: OWNER/MANAGER
Credential:
Phone: 405-224-2858