Healthcare Provider Details

I. General information

NPI: 1407938202
Provider Name (Legal Business Name): PHARM VINITA ACQUISITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 04/01/2022
Certification Date: 04/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 N SCRAPER ST
VINITA OK
74301-3209
US

IV. Provider business mailing address

201 N SCRAPER ST
VINITA OK
74301-3209
US

V. Phone/Fax

Practice location:
  • Phone: 918-256-2541
  • Fax: 918-256-5295
Mailing address:
  • Phone: 918-256-2541
  • Fax: 918-256-5295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number37-5146
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW FINN
Title or Position: OFFICER
Credential:
Phone: 918-256-2541