Provider Demographics
NPI:1811995301
Name:OKEMAH PHARMACY INC.
Entity type:Organization
Organization Name:OKEMAH PHARMACY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:FRECH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:918-652-3361
Mailing Address - Street 1:623 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-4245
Mailing Address - Country:US
Mailing Address - Phone:918-652-3361
Mailing Address - Fax:918-652-9554
Practice Address - Street 1:623 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4245
Practice Address - Country:US
Practice Address - Phone:918-652-3361
Practice Address - Fax:918-652-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-08
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14-5411332B00000X
3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234550DMedicaid
0568860003Medicare NSC