Healthcare Provider Details

I. General information

NPI: 1497806483
Provider Name (Legal Business Name): UNITED PHARMACY OF MANGUM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LOUIS TITTLE AVE
MANGUM OK
73554-2210
US

IV. Provider business mailing address

1000 N LOUIS TITTLE AVE
MANGUM OK
73554-2210
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-5400
  • Fax: 580-782-5404
Mailing address:
  • Phone: 580-782-5400
  • Fax: 580-782-5404

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 Number60-4910
License Number StateOK

VIII. Authorized Official

Name: BRADLEY BANISTER
Title or Position: OWNER AND PHARMACIST
Credential: PHRMD
Phone: 580-782-5400