Provider Demographics
NPI:1386768067
Name:STILWELL PHARMACY
Entity type:Organization
Organization Name:STILWELL PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER AND MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:PINKERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-696-2500
Mailing Address - Street 1:202 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960-3806
Mailing Address - Country:US
Mailing Address - Phone:918-696-2500
Mailing Address - Fax:918-696-5556
Practice Address - Street 1:202 S 2ND ST
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960-3806
Practice Address - Country:US
Practice Address - Phone:918-696-2500
Practice Address - Fax:918-696-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BC3200X, 3336C0003X, 3336C0004X, 3336S0011X
OK463613333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100233940AMedicaid
2073261OtherPK
AR161451407Medicaid
AR161451407Medicaid