MEDICARE: OKMULGEE DISCOUNT 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
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	333600000X	Pharmacy
3	3336L0003X	Long Term Care Pharmacy
4	3336C0003X	Community/Retail Pharmacy	143741	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2074685	OTHER	PK
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1518050954
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKMULGEE DISCOUNT PHARMACY, LLC

Provider Business Mailing Address
First Line	:	744 S MISSISSIPPI AVE STE A
Second Line	:
City	:	ATOKA
State	:	OK
Zip	:	74525-3356
Country	:	US
Telephone Number	:	580-889-0230
Fax Number	:	918-756-3205

Provider Business Practice Location Address
First Line	:	1160 S BELMONT AVE
Second Line	:
City	:	OKMULGEE
State	:	OK
Zip	:	74447-6308
Country	:	US
Telephone Number	:	918-756-1223
Fax Number	:	918-756-3205

Authorized Official
Title or Position	:	OWNER
Name	:	RYAN JAY RITTER
Credential	:
Telephone Number	:	580-889-3353

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	02/10/2022

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Directions to “OKMULGEE DISCOUNT PHARMACY, LLC ” Practice Location

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