MEDICARE: PALACE DRUG OF COALGATE 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	3336L0003X	Long Term Care Pharmacy
2	3336C0003X	Community/Retail Pharmacy	74-7690	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2072710	OTHER		PK

General Provider Information

NPI Number	:	1780767731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALACE DRUG OF COALGATE LLC

Provider Business Mailing Address
First Line	:	PO BOX 273
Second Line	:
City	:	COALGATE
State	:	OK
Zip	:	74538-0273
Country	:	US
Telephone Number	:	580-927-2064
Fax Number	:	580-927-2508

Provider Business Practice Location Address
First Line	:	104 W OHIO AVE
Second Line	:
City	:	COALGATE
State	:	OK
Zip	:	74538-2827
Country	:	US
Telephone Number	:	580-927-2064
Fax Number	:	580-927-2508

Authorized Official
Title or Position	:	OWNER
Name	:	JARED COLLINS
Credential	:
Telephone Number	:	580-927-2064

Provider Enumeration Date	:	10/23/2006
Last Update Date	:	10/07/2021

Similar Medicare Providers

1972545820 — RICHARD J HELTON
Practice Location Address:

108 W OHIO
COALGATE, OK
74538-2827

Practice Phone: 580-927-2334
Practice Fax: 580-927-9941

1700063229 — RICHARD J HELTON
Practice Location Address:

108 W OHIO AVE
COALGATE, OK
74538-2827

Practice Phone: 580-927-2334
Practice Fax: 580-927-9941

1720265945 — HELTON RURAL HEALTH CLINIC
Practice Location Address:

108 W OHIO AVE
COALGATE, OK
74538-2827

Practice Phone: 580-927-2334
Practice Fax: 580-927-9941

1326216839 — RICHARD J HELTON
Practice Location Address:

108 W OHIO AVE
COALGATE, OK
74538-2827

Practice Phone: 580-927-2334
Practice Fax: 580-927-9941

1003154725 — QUINTON TY BOHANNON P.A.-C
Practice Location Address:

108 W OHIO AVE
COALGATE, OK
74538-2827

Practice Phone: 580-927-2334
Practice Fax:

1457769473 — XYZ MEDICAL LLC
Practice Location Address:

104 W OHIO AVE STE 200
COALGATE, OK
74538-2827

Practice Phone: 918-423-7191
Practice Fax:

Directions to “PALACE DRUG OF COALGATE LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.