Provider Demographics
NPI:1093911604
Name:ERNIES PHARMACY & WELLNESS CENTER
Entity Type:Organization
Organization Name:ERNIES PHARMACY & WELLNESS CENTER
Other - Org Name:ERNIES PHARMACY AND WELLNESS CENTER INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SYKORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-682-7085
Mailing Address - Street 1:410 S 32ND ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-5007
Mailing Address - Country:US
Mailing Address - Phone:918-683-0611
Mailing Address - Fax:918-683-0620
Practice Address - Street 1:410 S 32ND ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-5007
Practice Address - Country:US
Practice Address - Phone:918-683-0611
Practice Address - Fax:918-683-0620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-21
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X
OK451883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200198680AMedicaid
2077137OtherPK
6361500001Medicare NSC