Healthcare Provider Details

I. General information

NPI: 1447630645
Provider Name (Legal Business Name): OWASSO DRUG COMPANY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2015
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12724 E 86TH ST N
OWASSO OK
74055-2548
US

IV. Provider business mailing address

12724 E 86TH ST N
OWASSO OK
74055-2548
US

V. Phone/Fax

Practice location:
  • Phone: 918-272-2881
  • Fax: 918-272-2883
Mailing address:
  • Phone: 918-272-2881
  • Fax: 918-272-2883

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 Number2-7287
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: MR. RYAN DEAN FLANARY
Title or Position: CO-OWNER
Credential:
Phone: 918-272-2881