Provider Demographics
NPI:1962753764
Name:PILL BOX PHARMACY LLC
Entity type:Organization
Organization Name:PILL BOX PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:MAST
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:918-512-6635
Mailing Address - Street 1:1329 S MAIN ST
Mailing Address - Street 2:UNIT C
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-5500
Mailing Address - Country:US
Mailing Address - Phone:918-512-6635
Mailing Address - Fax:918-512-6658
Practice Address - Street 1:1329 S MAIN ST UNIT C
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-5505
Practice Address - Country:US
Practice Address - Phone:918-512-6635
Practice Address - Fax:918-512-6638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK11-60643336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200458560AMedicaid
2137125OtherPK