Provider Demographics
NPI:1891874566
Name:SOONER PHARMACY INC OF TISHOMINGO
Entity Type:Organization
Organization Name:SOONER PHARMACY INC OF TISHOMINGO
Other - Org Name:SOONER PHARMACY INC OF TISHOMINGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES AND MGR
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-371-9509
Mailing Address - Street 1:101 S BYRD ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-2216
Mailing Address - Country:US
Mailing Address - Phone:580-371-9509
Mailing Address - Fax:580-371-9252
Practice Address - Street 1:101 S BYRD ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-2216
Practice Address - Country:US
Practice Address - Phone:580-371-9509
Practice Address - Fax:580-371-9252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK61-34933336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3714575OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100238360AMedicaid
0878360001Medicare NSC