Healthcare Provider Details

I. General information

NPI: 1306936836
Provider Name (Legal Business Name): PRAGUE GROCERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 W MAIN 3301 NBU
PRAGUE OK
74864
US

IV. Provider business mailing address

1000 W MAIN 3301 NBU
PRAGUE OK
74864
US

V. Phone/Fax

Practice location:
  • Phone: 405-567-4000
  • Fax: 405-567-4883
Mailing address:
  • Phone: 405-567-4000
  • Fax: 405-567-4883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number312129
License Number StateOK

VIII. Authorized Official

Name: MELINDA MAY FISHER
Title or Position: PHARMACY MANAGER
Credential:
Phone: 405-567-4000