Provider Demographics
NPI:1225020811
Name:TAHLEQUAH DRUG COMPANY LLC
Entity Type:Organization
Organization Name:TAHLEQUAH DRUG COMPANY LLC
Other - Org Name:TAHLEQUAH DRUG COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANON
Authorized Official - Middle Name:
Authorized Official - Last Name:GOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-931-9222
Mailing Address - Street 1:2028 MAHANEY AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5783
Mailing Address - Country:US
Mailing Address - Phone:918-431-0555
Mailing Address - Fax:918-431-0316
Practice Address - Street 1:2028 MAHANEY AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5783
Practice Address - Country:US
Practice Address - Phone:918-431-0555
Practice Address - Fax:918-431-0316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X, 3336L0003X
OK36-48243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200033290AMedicaid
2076569OtherPK
5976800001Medicare NSC