Provider Demographics
NPI:1275510471
Name:GLN OF HOLDENVILLE, INC
Entity Type:Organization
Organization Name:GLN OF HOLDENVILLE, INC
Other - Org Name:NICHOLS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-379-3381
Mailing Address - Street 1:203 E HIGHWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-4011
Mailing Address - Country:US
Mailing Address - Phone:405-379-3381
Mailing Address - Fax:405-379-3962
Practice Address - Street 1:203 E HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-4011
Practice Address - Country:US
Practice Address - Phone:405-379-3381
Practice Address - Fax:405-379-3962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK40-4623333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200002680AMedicaid
OK3713650OtherNCPDP
OK200002680AMedicaid