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NPI Code Detail

MEDICARE: 23RD STREET PHARMACY LLC

MEDICARE: 23RD STREET PHARMACY LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
13336L0003XLong Term Care Pharmacy
23336C0003XCommunity/Retail Pharmacy16693OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12133976OTHERPK

General Provider Information

NPI Number : 1215202064
Entity Type Code : Organization
Provider Name (Legal Business Name) : 23RD STREET PHARMACY LLC
Provider Business Mailing Address
First Line : 2316 NW 23RD ST
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73107-2406
Country : US
Telephone Number : 405-602-6442
Fax Number : 405-602-6449
Provider Business Practice Location Address
First Line : 2316 NW 23RD ST
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73107-2406
Country : US
Telephone Number : 405-602-6442
Fax Number : 405-602-6449
Authorized Official
Title or Position : OWNER
Name : MICKEY PHAN
Credential :
Telephone Number : 405-513-0710
Provider Enumeration Date : 03/13/2012
Last Update Date : 06/16/2016

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Directions to “23RD STREET PHARMACY LLC ” Practice Location

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