Provider Demographics
NPI:1235613886
Name:APS 1705, LLC
Entity Type:Organization
Organization Name:APS 1705, LLC
Other - Org Name:APS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-726-9845
Mailing Address - Street 1:1705 RENAISSANCE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3045
Mailing Address - Country:US
Mailing Address - Phone:405-726-9845
Mailing Address - Fax:405-726-9846
Practice Address - Street 1:1705 RENAISSANCE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3045
Practice Address - Country:US
Practice Address - Phone:405-726-9845
Practice Address - Fax:405-726-9846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200809200AMedicaid