Healthcare Provider Details

I. General information

NPI: 1134545999
Provider Name (Legal Business Name): OLIVERS EXPRESS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2014
Last Update Date: 05/14/2020
Certification Date: 05/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 N MAIN ST
FAIRVIEW OK
73737-1216
US

IV. Provider business mailing address

PO BOX 250
FAIRVIEW OK
73737-0250
US

V. Phone/Fax

Practice location:
  • Phone: 580-227-4000
  • Fax: 580-227-4003
Mailing address:
  • Phone: 580-227-4000
  • Fax: 580-227-4003

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 Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: OLIVER GARY LACKEY
Title or Position: OWNER/PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 580-744-1401