Healthcare Provider Details

I. General information

NPI: 1003998980
Provider Name (Legal Business Name): CENTRAL OKLAHOMA FAMILY MEDICAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 11/15/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 W 3RD ST
KONAWA OK
74849-1415
US

IV. Provider business mailing address

PO BOX 358
KONAWA OK
74849-0358
US

V. Phone/Fax

Practice location:
  • Phone: 580-925-8911
  • Fax: 580-925-8920
Mailing address:
  • Phone: 580-925-8911
  • Fax: 580-925-8920

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 Number244685
License Number StateOK

VIII. Authorized Official

Name: BLAKE WORLUND
Title or Position: PIC
Credential: PHARMD
Phone: 580-925-8911