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General NPI Number Information
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NPI Number | 1346988565
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Entity Type | Organization
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Legal Business Name | PRAIRIE GARDENS PHARMACY LTC INC
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Dates
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Enumeration Date | 05/26/2022
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Last Update Date | 11/18/2022
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Provider Practice Location Address
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Address Line | 12301 N WESTERN AVE STE 106
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City | OKLAHOMA CITY
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State | OK
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Zip | 73114-8017
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Country | US
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Telephone | 405-768-1818
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Fax | 405-768-1919
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Provider Business Mailing Address
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Address Line | 824 S WALNUT ST
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City | STILLWATER
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State | OK
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Zip | 74074-4225
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Country | US
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Telephone | 918-510-0648
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | TROY SIMONS
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Credential | DPH
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Telephone | 405-742-8099
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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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