Healthcare Provider Details

I. General information

NPI: 1770647109
Provider Name (Legal Business Name): FLOURISH INTEGRATIVE PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14720 N PENNSYLVANIA AVE
OKLAHOMA CITY OK
73134-6120
US

IV. Provider business mailing address

14720 N PENN AVE
OKLAHOMA CITY OK
73134-6120
US

V. Phone/Fax

Practice location:
  • Phone: 405-751-3333
  • Fax: 405-751-3848
Mailing address:
  • Phone: 405-751-3333
  • Fax: 405-751-3848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1-6316
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JERROD ROBERTS
Title or Position: OWNER
Credential: DPH
Phone: 405-751-3333