Provider Demographics
NPI:1316029119
Name:RT FAMILY DISCOUNT PHARMACY
Entity Type:Organization
Organization Name:RT FAMILY DISCOUNT PHARMACY
Other - Org Name:FAMILY DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-762-6335
Mailing Address - Street 1:310 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2001
Mailing Address - Country:US
Mailing Address - Phone:580-762-6335
Mailing Address - Fax:580-762-4210
Practice Address - Street 1:310 FAIRVIEW
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2001
Practice Address - Country:US
Practice Address - Phone:580-762-6335
Practice Address - Fax:580-762-4210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336S0011X
OK6-55463336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234470BMedicaid
OK100234470AMedicaid
3701794OtherNCPDP PROVIDER IDENTIFICATION NUMBER
1123750001Medicare NSC