Provider Demographics
NPI:1770647109
Name:FLOURISH INTEGRATIVE PHARMACY LLC
Entity Type:Organization
Organization Name:FLOURISH INTEGRATIVE PHARMACY LLC
Other - Org Name:FLOURISH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERROD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-751-3333
Mailing Address - Street 1:14720 N PENN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-6120
Mailing Address - Country:US
Mailing Address - Phone:405-751-3333
Mailing Address - Fax:405-751-3848
Practice Address - Street 1:14720 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-6120
Practice Address - Country:US
Practice Address - Phone:405-751-3333
Practice Address - Fax:405-751-3848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-63163336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail PharmacyGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2076566OtherPK