Healthcare Provider Details

I. General information

NPI: 1295804920
Provider Name (Legal Business Name): GRANITE DRUG, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 MAIN ST
GRANITE OK
73547-0158
US

IV. Provider business mailing address

PO BOX 158
GRANITE OK
73547-0158
US

V. Phone/Fax

Practice location:
  • Phone: 580-535-2130
  • Fax: 580-535-2001
Mailing address:
  • Phone:
  • Fax: 580-535-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number601729
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100232860A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier2072794
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: LIONEL CROSS
Title or Position: PHARM IN CHARGE
Credential: DPH
Phone: 580-535-2130