Provider Demographics
NPI:1770676108
Name:CENTRAL PHARMACY
Entity Type:Organization
Organization Name:CENTRAL PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:
Authorized Official - Last Name:AVANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-310-2014
Mailing Address - Street 1:PO BOX 722580
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-8961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1721 N MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-2000
Practice Address - Country:US
Practice Address - Phone:580-482-3414
Practice Address - Fax:580-482-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK1747183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100245240AMedicaid
3703445OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3703445OtherOTHER ID NUMBER