=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952515140
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN IGA PHARMACY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 NE 23RD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-424-4361
-----------------------------------------------------
Fax | 405-424-4362
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2001 NE 23RD
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-424-4361
-----------------------------------------------------
Fax | 405-424-4362
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMACY MANAGER
-----------------------------------------------------
Name | DR. LESLIE F GOODMAN
-----------------------------------------------------
Credential | DR
-----------------------------------------------------
Telephone | 405-424-4361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 9854
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------