Healthcare Provider Details

I. General information

NPI: 1003076738
Provider Name (Legal Business Name): OLYMPIA PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 02/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6802 S OLYMPIA AVE STE 125
TULSA OK
74132-1823
US

IV. Provider business mailing address

6802 S OLYMPIA AVE STE 125
TULSA OK
74132-1823
US

V. Phone/Fax

Practice location:
  • Phone: 918-398-6279
  • Fax:
Mailing address:
  • Phone: 918-398-6279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number25302
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SHAWN CRISMON
Title or Position: PHARMACIST
Credential: DPH
Phone: 918-388-5713