Provider Demographics
NPI:1962593566
Name:FISHERS CENTRAL DRUG STORE INC
Entity type:Organization
Organization Name:FISHERS CENTRAL DRUG STORE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:BAYER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:405-372-6120
Mailing Address - Street 1:722 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4668
Mailing Address - Country:US
Mailing Address - Phone:405-372-6120
Mailing Address - Fax:405-372-2833
Practice Address - Street 1:722 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4668
Practice Address - Country:US
Practice Address - Phone:405-372-6120
Practice Address - Fax:405-372-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8-40393336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100237050AMedicaid
BC4982446OtherDEA
OK100237050AMedicaid