=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942365879
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY PHARMACY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2006
-----------------------------------------------------
Last Update Date | 08/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3125 SW 89TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-605-7700
-----------------------------------------------------
Fax | 405-605-7712
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3125 SW 89TH ST
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73159-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ED GRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-419-5478
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 15137
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------