Provider Demographics
NPI:1306867379
Name:MISSION HOSPICE LLC
Entity Type:Organization
Organization Name:MISSION HOSPICE LLC
Other - Org Name:PIETA PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-841-3841
Mailing Address - Street 1:1608 NW EXPRESSWAY ST
Mailing Address - Street 2:STE B
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-1402
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1608 NW EXPRESSWAY ST
Practice Address - Street 2:STE B
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-1402
Practice Address - Country:US
Practice Address - Phone:405-841-3841
Practice Address - Fax:405-841-3843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK151563336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3721013OtherOTHER ID NUMBER-COMMERCIAL NUMBER