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General NPI Number Information
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NPI Number | 1124642178
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Entity Type | Organization
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Legal Business Name | PHARMOLOGY TISHMINGO ACQUISITION LLC
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Dates
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Enumeration Date | 06/05/2020
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Last Update Date | 12/15/2020
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Provider Practice Location Address
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Address Line | 140 E MAIN ST
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City | TISHOMINGO
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State | OK
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Zip | 73460-2838
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Country | US
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Telephone | 580-371-2355
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Fax | 580-371-0000
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Provider Business Mailing Address
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Address Line | 744 S MISSISSIPPI AVE STE A
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City | ATOKA
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State | OK
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Zip | 74525-3356
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Country | US
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Telephone | 580-371-2355
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Fax | 580-371-0000
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Authorized Official
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Title or Position | OWNER
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Name | SUSAN RITTER
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Credential | DPH
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Telephone | 580-889-0230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number |
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License Number State |
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