Provider Demographics
NPI:1679650543
Name:P & S PHARMACY INC
Entity Type:Organization
Organization Name:P & S PHARMACY INC
Other - Org Name:P AND S PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-379-5431
Mailing Address - Street 1:PO BOX 71
Mailing Address - Street 2:
Mailing Address - City:HOLDENVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74848-0071
Mailing Address - Country:US
Mailing Address - Phone:405-379-5431
Mailing Address - Fax:405-379-3474
Practice Address - Street 1:820 E HIGHWAY ST
Practice Address - Street 2:
Practice Address - City:HOLDENVILLE
Practice Address - State:OK
Practice Address - Zip Code:74848-4227
Practice Address - Country:US
Practice Address - Phone:405-379-5431
Practice Address - Fax:405-379-3474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK40-22743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3712381OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100236090AMedicaid
OK100236090AMedicaid