Provider Demographics
NPI:1235688060
Name:MUSTANG DRUG LLC
Entity Type:Organization
Organization Name:MUSTANG DRUG LLC
Other - Org Name:MUSTANG DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER/ PHARMACIST-IN-CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:SELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALAMI
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-256-0555
Mailing Address - Street 1:103 E STATE HIGHWAY 152
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-4406
Mailing Address - Country:US
Mailing Address - Phone:405-256-0555
Mailing Address - Fax:405-256-0565
Practice Address - Street 1:103 E STATE HIGHWAY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4406
Practice Address - Country:US
Practice Address - Phone:405-256-0555
Practice Address - Fax:405-256-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200682900AMedicaid
2164331OtherPK