Healthcare Provider Details

I. General information

NPI: 1669777058
Provider Name (Legal Business Name): THACKERVILLE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 03/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11530 RIDGE RD STE 1
THACKERVILLE OK
73459-9623
US

IV. Provider business mailing address

11530 RIDGE RD SUITE 1
THACKERVILLE OK
73459-9622
US

V. Phone/Fax

Practice location:
  • Phone: 580-276-5161
  • Fax: 580-276-9063
Mailing address:
  • Phone: 580-276-5161
  • Fax: 580-276-9063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number72-5917
License Number StateOK

VIII. Authorized Official

Name: SUSAN SOUTH
Title or Position: MANAGER
Credential:
Phone: 580-276-5161