Provider Demographics
NPI:1518357151
Name:SPRING CREEK PHARMACY LLC
Entity Type:Organization
Organization Name:SPRING CREEK PHARMACY LLC
Other - Org Name:SPRING CREEK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:MACVICTOR
Authorized Official - Middle Name:VIET KY
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-285-9082
Mailing Address - Street 1:1218 E 9TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-5796
Mailing Address - Country:US
Mailing Address - Phone:405-285-9082
Mailing Address - Fax:405-471-6256
Practice Address - Street 1:1218 E 9TH ST STE 1
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-5796
Practice Address - Country:US
Practice Address - Phone:405-285-9082
Practice Address - Fax:405-471-6256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2149145OtherPK
OK200576880AMedicaid