Provider Demographics
NPI:1043956832
Name:MIDTOWN DRUG
Entity Type:Organization
Organization Name:MIDTOWN DRUG
Other - Org Name:MIDTOWN DRUG, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHONG
Authorized Official - Middle Name:
Authorized Official - Last Name:HOANG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-768-1002
Mailing Address - Street 1:525 NW 11TH ST STE 112
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-2405
Mailing Address - Country:US
Mailing Address - Phone:405-768-1002
Mailing Address - Fax:
Practice Address - Street 1:525 NW 11TH ST STE 112
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-2405
Practice Address - Country:US
Practice Address - Phone:405-768-1002
Practice Address - Fax:888-626-6036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201106790AMedicaid