Healthcare Provider Details

I. General information

NPI: 1417661760
Provider Name (Legal Business Name): 412 FAMILY PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E MAIN ST
LOCUST GROVE OK
74352-5117
US

IV. Provider business mailing address

PO BOX 700
INOLA OK
74036-0700
US

V. Phone/Fax

Practice location:
  • Phone: 918-479-5223
  • Fax: 918-479-6510
Mailing address:
  • Phone: 918-543-8777
  • Fax: 918-543-2013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PAUL ANDREW TURNER
Title or Position: OWNER
Credential:
Phone: 918-543-8777