Provider Demographics
NPI:1497806483
Name:UNITED PHARMACY OF MANGUM LLC
Entity Type:Organization
Organization Name:UNITED PHARMACY OF MANGUM LLC
Other - Org Name:UNITED PHARMACY OF MANGUM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BANISTER
Authorized Official - Suffix:
Authorized Official - Credentials:PHRMD
Authorized Official - Phone:580-782-5400
Mailing Address - Street 1:1000 N LOUIS TITTLE AVE
Mailing Address - Street 2:
Mailing Address - City:MANGUM
Mailing Address - State:OK
Mailing Address - Zip Code:73554-2210
Mailing Address - Country:US
Mailing Address - Phone:580-782-5400
Mailing Address - Fax:580-782-5404
Practice Address - Street 1:1000 N LOUIS TITTLE AVE
Practice Address - Street 2:
Practice Address - City:MANGUM
Practice Address - State:OK
Practice Address - Zip Code:73554-2210
Practice Address - Country:US
Practice Address - Phone:580-782-5400
Practice Address - Fax:580-782-5404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK60-49103336C0003X
OK6049103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200046200AMedicaid
2076977OtherPK