Provider Demographics
NPI:1174179154
Name:LONE GROVE PHARMACY LLC
Entity Type:Organization
Organization Name:LONE GROVE PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:III
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-301-7681
Mailing Address - Street 1:4750 TRAVERTINE APT 722
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5594
Mailing Address - Country:US
Mailing Address - Phone:405-301-7681
Mailing Address - Fax:
Practice Address - Street 1:45 ALMOND DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2405
Practice Address - Country:US
Practice Address - Phone:405-301-7681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy