Healthcare Provider Details

I. General information

NPI: 1235215807
Provider Name (Legal Business Name): SAM THORNBROUGH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WATTS ST
SAYRE OK
73662-1314
US

IV. Provider business mailing address

PO BOX 99
SAYRE OK
73662-0099
US

V. Phone/Fax

Practice location:
  • Phone: 580-928-3058
  • Fax: 580-928-3873
Mailing address:
  • Phone: 580-928-3058
  • Fax: 580-928-3873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number351906
License Number StateOK

VIII. Authorized Official

Name: SAM THORNBROUGH
Title or Position: OWNER
Credential:
Phone: 580-928-3058