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General NPI Number Information
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NPI Number | 1881769487
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Entity Type | Organization
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Legal Business Name | JACK JUSTICE
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Dates
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Enumeration Date | 11/21/2006
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Last Update Date | 02/05/2021
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Provider Practice Location Address
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Address Line | 500 WILLIAMS
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City | MAYSVILLE
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State | OK
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Zip | 73057-3679
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Country | US
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Telephone | 405-867-4427
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Fax | 405-867-5267
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Provider Business Mailing Address
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Address Line | PO BOX 217
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City | MAYSVILLE
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State | OK
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Zip | 73057-0217
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Country | US
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Telephone | 405-867-4427
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Fax | 405-867-5267
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | JULIE JUSTICE
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Credential |
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Telephone | 405-447-3911
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | 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 | 22-4098
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License Number State | OK
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