Provider Demographics
NPI:1174827273
Name:KINGFISHER PHARMACY MANAGEMENT PLLC
Entity Type:Organization
Organization Name:KINGFISHER PHARMACY MANAGEMENT PLLC
Other - Org Name:MEDIC PHARMACY AND GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUENERGARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-938-2854
Mailing Address - Street 1:119 W ADMIRE AVE
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-2609
Mailing Address - Country:US
Mailing Address - Phone:405-375-3202
Mailing Address - Fax:405-375-6739
Practice Address - Street 1:119 W ADMIRE AVE
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-2609
Practice Address - Country:US
Practice Address - Phone:405-375-3202
Practice Address - Fax:405-375-6739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
OK54-56173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200323020AMedicaid
2128250OtherPK