Healthcare Provider Details

I. General information

NPI: 1124642178
Provider Name (Legal Business Name): PHARMOLOGY TISHMINGO ACQUISITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E MAIN ST
TISHOMINGO OK
73460-2838
US

IV. Provider business mailing address

744 S MISSISSIPPI AVE STE A
ATOKA OK
74525-3356
US

V. Phone/Fax

Practice location:
  • Phone: 580-371-2355
  • Fax: 580-371-0000
Mailing address:
  • Phone: 580-371-2355
  • Fax: 580-371-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUSAN RITTER
Title or Position: OWNER
Credential: DPH
Phone: 580-889-0230