Provider Demographics
NPI:1225168537
Name:ROLAND PHARMACY INC
Entity Type:Organization
Organization Name:ROLAND PHARMACY INC
Other - Org Name:ROLAND PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERRYE
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-427-3219
Mailing Address - Street 1:PO BOX 520
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-0520
Mailing Address - Country:US
Mailing Address - Phone:918-427-3219
Mailing Address - Fax:918-427-3210
Practice Address - Street 1:100 E RAY FINE BLVD
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5198
Practice Address - Country:US
Practice Address - Phone:918-427-3219
Practice Address - Fax:918-427-3210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
OK3423343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100806610BMedicaid
AR130941407Medicaid
2073727OtherPK
AR130941407Medicaid
OK310115OtherSTATE TAX ID#