MEDICARE: THOMAS WILSON PHARMACY INC

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	333600000X	Pharmacy
2	3336C0004X	Compounding Pharmacy
3	3336C0003X	Community/Retail Pharmacy	1-7280	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	2081553	OTHER	PK

General Provider Information

NPI Number	:	1669576625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS WILSON PHARMACY INC

Provider Business Mailing Address
First Line	:	911 S AIR DEPOT BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-4836
Country	:	US
Telephone Number	:	405-737-3464
Fax Number	:	405-737-9554

Provider Business Practice Location Address
First Line	:	911 S AIR DEPOT BLVD
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73110-4836
Country	:	US
Telephone Number	:	405-737-3464
Fax Number	:	405-737-9554

Authorized Official
Title or Position	:	OWNER/PHARMACIST/PRESIDENT
Name	:	STEVEN MATLOCK
Credential	:
Telephone Number	:	405-737-3464

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	10/25/2021

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Directions to “THOMAS WILSON PHARMACY INC ” Practice Location

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