Provider Demographics
NPI:1083352066
Name:PRAIRIE GARDENS PHARMACY INC
Entity Type:Organization
Organization Name:PRAIRIE GARDENS PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-742-8099
Mailing Address - Street 1:824 S WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4225
Mailing Address - Country:US
Mailing Address - Phone:405-768-1818
Mailing Address - Fax:
Practice Address - Street 1:12301 N WESTERN AVE STE 106
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-8017
Practice Address - Country:US
Practice Address - Phone:405-768-1818
Practice Address - Fax:405-768-1919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-20
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1-9220OtherOKLAHOMA STATE BOARD OF PHARMACY