Provider Demographics
NPI:1003909441
Name:PAWNEE HILLCREST PHARMACY ENTERPRISES, LLC
Entity Type:Organization
Organization Name:PAWNEE HILLCREST PHARMACY ENTERPRISES, LLC
Other - Org Name:PAWNEE HILLCREST PHARMACY INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHARMACIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-762-3666
Mailing Address - Street 1:539 6TH STREET
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-2542
Mailing Address - Country:US
Mailing Address - Phone:918-762-3666
Mailing Address - Fax:918-762-2288
Practice Address - Street 1:539 6TH STREET
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-2542
Practice Address - Country:US
Practice Address - Phone:918-762-3666
Practice Address - Fax:918-762-2288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5227423336C0003X
3336C0003X, 3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073056OtherPK
OK100238450AMedicaid
OK90003919628Medicaid