Healthcare Provider Details

I. General information

NPI: 1093911604
Provider Name (Legal Business Name): ERNIES PHARMACY & WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S 32ND ST
MUSKOGEE OK
74401-5007
US

IV. Provider business mailing address

410 S 32ND ST
MUSKOGEE OK
74401-5007
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-0611
  • Fax: 918-683-0620
Mailing address:
  • Phone: 918-683-0611
  • Fax: 918-683-0620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number45188
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: ERNIE SYKORA
Title or Position: OWNER
Credential:
Phone: 918-682-7085