Provider Demographics
NPI:1730108770
Name:SALLISAW PHARMACY INC
Entity Type:Organization
Organization Name:SALLISAW PHARMACY INC
Other - Org Name:SALLISAW PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:RISLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-775-4451
Mailing Address - Street 1:1212A E CHEROKEE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-5231
Mailing Address - Country:US
Mailing Address - Phone:918-775-4451
Mailing Address - Fax:918-775-5269
Practice Address - Street 1:1212A E CHEROKEE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-5231
Practice Address - Country:US
Practice Address - Phone:918-775-4451
Practice Address - Fax:918-775-5269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK34-30713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100237570AMedicaid
2073858OtherPK
1034380001Medicare NSC
1034380001Medicare NSC