Provider Demographics
NPI:1285645846
Name:DRUG STORE
Entity type:Organization
Organization Name:DRUG STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER MGR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-733-2881
Mailing Address - Street 1:2801 PARKLAWN DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 PARKLAWN DR STE 102
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4224
Practice Address - Country:US
Practice Address - Phone:405-733-2881
Practice Address - Fax:405-733-3007
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X
OK13941333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3709447OtherOTHER ID NUMBER-COMMERCIAL NUMBER
OK0370230001Medicare NSC