Healthcare Provider Details

I. General information

NPI: 1073952354
Provider Name (Legal Business Name): PATRIOT PHARMACIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2013
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 S ELM ST STE 130
JENKS OK
74037-3777
US

IV. Provider business mailing address

329 S ELM ST STE 130
JENKS OK
74037-3777
US

V. Phone/Fax

Practice location:
  • Phone: 918-298-4153
  • Fax: 918-298-4272
Mailing address:
  • Phone: 918-298-4153
  • Fax: 918-298-4272

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 Number2-7611
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DAVID O'ROURKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 918-298-4153