Provider Demographics
NPI:1457440141
Name:ROYS DISCOUNT PHARMACY LLC
Entity Type:Organization
Organization Name:ROYS DISCOUNT PHARMACY LLC
Other - Org Name:ROYS DISCOUNT PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MILENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-465-0111
Mailing Address - Street 1:621 HIGHWAY 2 N
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-3620
Mailing Address - Country:US
Mailing Address - Phone:918-465-0111
Mailing Address - Fax:918-465-0015
Practice Address - Street 1:621 HIGHWAY 2 N
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-3620
Practice Address - Country:US
Practice Address - Phone:918-465-0111
Practice Address - Fax:918-465-0015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
OK67-45543336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100247050AMedicaid
2074672OtherPK
4597560001Medicare NSC