Provider Demographics
NPI:1942340898
Name:COMMUNITY PHARMACY, LLC
Entity Type:Organization
Organization Name:COMMUNITY PHARMACY, LLC
Other - Org Name:FOUNTAIN PARK PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-419-7716
Mailing Address - Street 1:205 NW 63RD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-8254
Mailing Address - Country:US
Mailing Address - Phone:405-419-7716
Mailing Address - Fax:
Practice Address - Street 1:3125 SW 89 ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159
Practice Address - Country:US
Practice Address - Phone:405-605-7700
Practice Address - Fax:405-605-7712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1-51373336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3724754OtherNCPDP