Healthcare Provider Details

I. General information

NPI: 1760523625
Provider Name (Legal Business Name): MIRANDA GREEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W AVENUE D
HEAVENER OK
74937-3017
US

IV. Provider business mailing address

101 W AVENUE D
HEAVENER OK
74937-3017
US

V. Phone/Fax

Practice location:
  • Phone: 918-653-4803
  • Fax: 918-653-3520
Mailing address:
  • Phone: 918-653-4803
  • Fax: 918-653-3520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number19-5501
License Number StateOK

VIII. Authorized Official

Name: MIRANDA GREEN
Title or Position: OWNER
Credential: PD
Phone: 918-653-4803