Provider Demographics
NPI:1083799373
Name:MCCORTNEY DRUG INC
Entity Type:Organization
Organization Name:MCCORTNEY DRUG INC
Other - Org Name:MCCORTNEYS FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-332-3344
Mailing Address - Street 1:711 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3807
Mailing Address - Country:US
Mailing Address - Phone:580-332-3344
Mailing Address - Fax:580-332-3616
Practice Address - Street 1:711 E 9TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3807
Practice Address - Country:US
Practice Address - Phone:580-332-3344
Practice Address - Fax:580-332-3616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
OK23-59783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100238510AMedicaid
2073507OtherPK
1236470001Medicare NSC