Provider Demographics
NPI:1053491357
Name:OKLAHOMA PHARMACY INC
Entity Type:Organization
Organization Name:OKLAHOMA PHARMACY INC
Other - Org Name:RIVERBEND SERV-U PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SASS
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:414-327-1150
Mailing Address - Street 1:7500 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53219-2860
Mailing Address - Country:US
Mailing Address - Phone:414-327-1150
Mailing Address - Fax:414-327-2251
Practice Address - Street 1:7500 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53219-2860
Practice Address - Country:US
Practice Address - Phone:414-327-1150
Practice Address - Fax:414-327-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6666332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33052200Medicaid
WI0255890001Medicare ID - Type Unspecified