Provider Demographics
NPI:1265442164
Name:CANADIAN VALLEY RX, INC.
Entity Type:Organization
Organization Name:CANADIAN VALLEY RX, INC.
Other - Org Name:CANADIAN VALLEY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER/MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-262-4154
Mailing Address - Street 1:1605 W. ELM STREET
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036
Mailing Address - Country:US
Mailing Address - Phone:405-262-4154
Mailing Address - Fax:405-262-0912
Practice Address - Street 1:1605 W. ELM STREET
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-262-4154
Practice Address - Fax:405-262-0912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BN1400X, 333600000X, 3336C0004X, 3336L0003X, 333600000X
OK26-80783336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100803650CMedicaid
OK100803650BMedicaid
2072539OtherPK
OK100803650BMedicaid