Provider Demographics
NPI:1346319837
Name:REXCO DRUG OF ALTUS INC
Entity Type:Organization
Organization Name:REXCO DRUG OF ALTUS INC
Other - Org Name:REXCO DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-477-0381
Mailing Address - Street 1:2101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1605
Mailing Address - Country:US
Mailing Address - Phone:580-477-0381
Mailing Address - Fax:580-477-1749
Practice Address - Street 1:2101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1605
Practice Address - Country:US
Practice Address - Phone:580-477-0381
Practice Address - Fax:580-477-1749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336L0003X
OK1752863336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074507OtherPK
OK100241510AMedicaid
1185960001Medicare PIN