Provider Demographics
NPI:1780659755
Name:LEGACY PHARMACY, LLC
Entity Type:Organization
Organization Name:LEGACY PHARMACY, LLC
Other - Org Name:LEGACY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTING
Authorized Official - Prefix:
Authorized Official - First Name:JULLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-447-3911
Mailing Address - Street 1:111 W GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-3257
Mailing Address - Country:US
Mailing Address - Phone:405-238-3305
Mailing Address - Fax:405-238-3307
Practice Address - Street 1:111 W GRANT AVE
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-3257
Practice Address - Country:US
Practice Address - Phone:405-238-3305
Practice Address - Fax:405-238-3307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-22
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074447OtherPK
OK200135440BMedicaid
OK400522112Medicare ID - Type UnspecifiedMEDICARE