Healthcare Provider Details

I. General information

NPI: 1215202064
Provider Name (Legal Business Name): 23RD STREET PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2012
Last Update Date: 06/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2316 NW 23RD ST
OKLAHOMA CITY OK
73107-2406
US

IV. Provider business mailing address

2316 NW 23RD ST
OKLAHOMA CITY OK
73107-2406
US

V. Phone/Fax

Practice location:
  • Phone: 405-602-6442
  • Fax: 405-602-6449
Mailing address:
  • Phone: 405-602-6442
  • Fax: 405-602-6449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number16693
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MICKEY PHAN
Title or Position: OWNER
Credential:
Phone: 405-513-0710