Healthcare Provider Details

I. General information

NPI: 1164774709
Provider Name (Legal Business Name): MATT'S COUNTRY BOY PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14890 SE 29TH ST STE 108
CHOCTAW OK
73020-3516
US

IV. Provider business mailing address

14890 SE 29TH ST STE 108
CHOCTAW OK
73020-3516
US

V. Phone/Fax

Practice location:
  • Phone: 405-390-3205
  • Fax: 405-390-2516
Mailing address:
  • Phone: 405-390-3205
  • Fax: 405-390-2516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number1-6052
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATT EVANS
Title or Position: PHARMACIST/OWNER
Credential:
Phone: 405-390-3205