Provider Demographics
NPI:1043393093
Name:PHILLIP W & PHYLLIS J MELTON
Entity Type:Organization
Organization Name:PHILLIP W & PHYLLIS J MELTON
Other - Org Name:APACHE DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:405-247-3081
Mailing Address - Street 1:PO BOX 315
Mailing Address - Street 2:
Mailing Address - City:APACHE
Mailing Address - State:OK
Mailing Address - Zip Code:73006-0315
Mailing Address - Country:US
Mailing Address - Phone:580-588-3639
Mailing Address - Fax:
Practice Address - Street 1:118 E EVANS
Practice Address - Street 2:
Practice Address - City:APACHE
Practice Address - State:OK
Practice Address - Zip Code:73006-9802
Practice Address - Country:US
Practice Address - Phone:580-588-3639
Practice Address - Fax:580-588-3638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2033273336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074309OtherPK
OK100804450CMedicaid
OK90003923018Medicaid