Provider Demographics
NPI:1316276637
Name:YUKON PHARMACY INC
Entity type:Organization
Organization Name:YUKON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHARMACIST-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:EMRY
Authorized Official - Last Name:HESTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-256-6653
Mailing Address - Street 1:520 S MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6737
Mailing Address - Country:US
Mailing Address - Phone:405-256-6653
Mailing Address - Fax:405-256-6647
Practice Address - Street 1:520 S MUSTANG RD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6737
Practice Address - Country:US
Practice Address - Phone:405-256-6653
Practice Address - Fax:405-256-6647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-15
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OK26-77753336C0003X, 3336C0003X
OK26-54903336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200276370AMedicaid
2123191OtherPK