Provider Demographics
NPI:1083625628
Name:SOONER PHARMACY OF DAVIS INC
Entity Type:Organization
Organization Name:SOONER PHARMACY OF DAVIS INC
Other - Org Name:SOONER PHARMACY OF DAVIS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:580-369-3776
Mailing Address - Street 1:705 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:OK
Mailing Address - Zip Code:73030-1913
Mailing Address - Country:US
Mailing Address - Phone:580-369-3776
Mailing Address - Fax:580-369-2115
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:OK
Practice Address - Zip Code:73030-1913
Practice Address - Country:US
Practice Address - Phone:580-369-3776
Practice Address - Fax:580-369-2115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OK55-42383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100238120AMedicaid
2073930OtherPK
OK100238120AMedicaid