Provider Demographics
NPI:1174856611
Name:CENTRAL OKLAHOMA FAMILY MEDICAL CENTER PHARMACY
Entity Type:Organization
Organization Name:CENTRAL OKLAHOMA FAMILY MEDICAL CENTER PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:F
Authorized Official - Last Name:VANDEGRIFT
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-925-8911
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-8911
Mailing Address - Fax:580-925-8920
Practice Address - Street 1:527 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-1415
Practice Address - Country:US
Practice Address - Phone:580-925-8911
Practice Address - Fax:580-925-8920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK244685333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100737160Medicaid
OK4894980001Medicare NSC