Provider Demographics
NPI:1346223328
Name:JOHNNYS HOMETOWN PHARMACY PC
Entity Type:Organization
Organization Name:JOHNNYS HOMETOWN PHARMACY PC
Other - Org Name:JOHNNYS HOMETOWN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-427-0400
Mailing Address - Street 1:PO BOX 1600
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-1600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 E RAY FINE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954-5362
Practice Address - Country:US
Practice Address - Phone:918-427-0400
Practice Address - Fax:918-427-0401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK3438413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100243100AMedicaid
AR140896407Medicaid
2074722OtherPK
OK100243100AMedicaid