Healthcare Provider Details

I. General information

NPI: 1780767731
Provider Name (Legal Business Name): PALACE DRUG OF COALGATE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W OHIO AVE
COALGATE OK
74538-2827
US

IV. Provider business mailing address

PO BOX 273
COALGATE OK
74538-0273
US

V. Phone/Fax

Practice location:
  • Phone: 580-927-2064
  • Fax: 580-927-2508
Mailing address:
  • Phone: 580-927-2064
  • Fax: 580-927-2508

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number74-7690
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JARED COLLINS
Title or Position: OWNER
Credential:
Phone: 580-927-2064