=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801936059
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TV DISCOUNT DRUG INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 02/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 W OKLAHOMA AVE
-----------------------------------------------------
City | GUTHRIE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73044-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-282-2700
-----------------------------------------------------
Fax | 405-282-4715
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 112 W OKLAHOMA AVE
-----------------------------------------------------
City | GUTHRIE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73044-3130
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-282-2700
-----------------------------------------------------
Fax | 405-282-4715
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BROOKE VAN HORN
-----------------------------------------------------
Credential | DPH
-----------------------------------------------------
Telephone | 405-348-0220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 323209
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------