Provider Demographics
NPI:1578856316
Name:OAKLEY PHARMACY INC
Entity Type:Organization
Organization Name:OAKLEY PHARMACY INC
Other - Org Name:DALE HOLLOW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:POLSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-243-3550
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:CELINA
Mailing Address - State:TN
Mailing Address - Zip Code:38551-0188
Mailing Address - Country:US
Mailing Address - Phone:931-243-3434
Mailing Address - Fax:931-243-3550
Practice Address - Street 1:201 MCARTHUR AVE
Practice Address - Street 2:
Practice Address - City:CELINA
Practice Address - State:TN
Practice Address - Zip Code:38551-4004
Practice Address - Country:US
Practice Address - Phone:931-243-3434
Practice Address - Fax:931-243-3550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TN00000038173336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2130431OtherPK
TN6060358Medicaid
2130431OtherPK