Provider Demographics
NPI:1952483752
Name:UNITED DISCOUNT DRUG INC
Entity Type:Organization
Organization Name:UNITED DISCOUNT DRUG INC
Other - Org Name:BROADWAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-477-0800
Mailing Address - Street 1:601 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5512
Mailing Address - Country:US
Mailing Address - Phone:580-477-0800
Mailing Address - Fax:580-477-0802
Practice Address - Street 1:601 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5512
Practice Address - Country:US
Practice Address - Phone:580-477-0800
Practice Address - Fax:580-477-0802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
OK1763553336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234180AMedicaid
OK100234180BMedicaid
2072623OtherPK
0833880001Medicare NSC
0833880001Medicare NSC