Provider Demographics
NPI:1487675443
Name:SIMPSONS PRAGUE PHARMACY PLLC
Entity Type:Organization
Organization Name:SIMPSONS PRAGUE PHARMACY PLLC
Other - Org Name:PRAGUE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:D PH
Authorized Official - Phone:405-567-4322
Mailing Address - Street 1:1020 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRAGUE
Mailing Address - State:OK
Mailing Address - Zip Code:74864-4501
Mailing Address - Country:US
Mailing Address - Phone:405-567-4322
Mailing Address - Fax:405-567-3303
Practice Address - Street 1:1020 W MAIN ST
Practice Address - Street 2:
Practice Address - City:PRAGUE
Practice Address - State:OK
Practice Address - Zip Code:74864-4501
Practice Address - Country:US
Practice Address - Phone:405-567-4322
Practice Address - Fax:405-567-3303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31-59533336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100247240AMedicaid
2073230OtherPK
2073230OtherPK