Healthcare Provider Details

I. General information

NPI: 1174827273
Provider Name (Legal Business Name): KINGFISHER PHARMACY MANAGEMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 01/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 W ADMIRE AVE
KINGFISHER OK
73750-2609
US

IV. Provider business mailing address

119 W ADMIRE AVE
KINGFISHER OK
73750-2609
US

V. Phone/Fax

Practice location:
  • Phone: 405-375-3202
  • Fax: 405-375-6739
Mailing address:
  • Phone: 405-375-3202
  • Fax: 405-375-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number54-5617
License Number StateOK

VIII. Authorized Official

Name: GREGORY HUENERGARDT
Title or Position: MEMBER MANAGER
Credential:
Phone: 580-938-2854