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General NPI Number Information
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NPI Number | 1750522421
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Entity Type | Organization
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Legal Business Name | LEGACY DRUG
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Dates
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Enumeration Date | 03/10/2009
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Last Update Date | 03/10/2009
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Provider Practice Location Address
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Address Line | 111 W GRANT AVE
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City | PAULS VALLEY
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State | OK
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Zip | 73075-3257
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Country | US
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Telephone | 405-238-3305
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Fax | 405-238-3307
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Provider Business Mailing Address
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Address Line | 111 W GRANT AVE
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City | PAULS VALLEY
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State | OK
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Zip | 73075-3257
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Country | US
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Telephone | 405-238-3305
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Fax | 405-238-3307
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Authorized Official
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Title or Position | PIC
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Name | MRS. EMILY MARIE SMITH
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Credential | D.PH.
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Telephone | 405-238-3305
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 22-5367
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License Number State | OK
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