Provider Demographics
NPI:1306936836
Name:PRAGUE GROCERY, LLC
Entity type:Organization
Organization Name:PRAGUE GROCERY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-567-4000
Mailing Address - Street 1:1000 W MAIN
Mailing Address - Street 2:3301 NBU
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864
Mailing Address - Country:US
Mailing Address - Phone:405-567-4000
Mailing Address - Fax:405-567-4883
Practice Address - Street 1:1000 W MAIN
Practice Address - Street 2:3301 NBU
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864
Practice Address - Country:US
Practice Address - Phone:405-567-4000
Practice Address - Fax:405-567-4883
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAGUE GROCERY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-13
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3121293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100238090AMedicaid