Provider Demographics
NPI:1326458563
Name:MATT ENNIS LLC
Entity Type:Organization
Organization Name:MATT ENNIS LLC
Other - Org Name:UNITED DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-947-6828
Mailing Address - Street 1:5420 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2072
Mailing Address - Country:US
Mailing Address - Phone:405-947-6828
Mailing Address - Fax:405-946-3346
Practice Address - Street 1:5420 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2072
Practice Address - Country:US
Practice Address - Phone:405-947-6828
Practice Address - Fax:405-946-3346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-28
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0003X, 3336C0004X
OK1-67083336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200536450AMedicaid
2145853OtherPK