Healthcare Provider Details

I. General information

NPI: 1669487534
Provider Name (Legal Business Name): ELGIN DISCOUNT PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7523 US HIGHWAY 277
ELGIN OK
73538-2161
US

IV. Provider business mailing address

7523 US HIGHWAY 277
ELGIN OK
73538-2161
US

V. Phone/Fax

Practice location:
  • Phone: 580-492-5007
  • Fax: 580-492-5090
Mailing address:
  • Phone: 580-492-5007
  • Fax: 580-492-5090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number35152
License Number StateOK

VIII. Authorized Official

Name: MARK DEEVERS
Title or Position: OWNER AND PRESIDENT MNGR
Credential:
Phone: 580-492-5007