Provider Demographics
NPI:1962721464
Name:RX SHOPPE INC
Entity type:Organization
Organization Name:RX SHOPPE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-786-1092
Mailing Address - Street 1:PO BOX 6598
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-6598
Mailing Address - Country:US
Mailing Address - Phone:918-786-1092
Mailing Address - Fax:918-786-4642
Practice Address - Street 1:901 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2845
Practice Address - Country:US
Practice Address - Phone:918-786-1092
Practice Address - Fax:918-786-4642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-24
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45-74183336C0003X
3336C0004X
OK45-55253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2125170OtherPK
OK200287880AMedicaid
2125170OtherPK