Provider Demographics
NPI:1326739749
Name:SALLISAWRX LLC
Entity type:Organization
Organization Name:SALLISAWRX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAKOTA
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:918-775-4451
Mailing Address - Street 1:1212A E CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-5232
Mailing Address - Country:US
Mailing Address - Phone:918-775-4451
Mailing Address - Fax:918-775-5269
Practice Address - Street 1:1212A E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5232
Practice Address - Country:US
Practice Address - Phone:918-775-4451
Practice Address - Fax:918-775-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100237570AMedicaid