Provider Demographics
NPI:1962509802
Name:THE CLINIC PHARMACY ON ARLINGTON
Entity Type:Organization
Organization Name:THE CLINIC PHARMACY ON ARLINGTON
Other - Org Name:TRADITION DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-436-5111
Mailing Address - Street 1:1131 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-4038
Mailing Address - Country:US
Mailing Address - Phone:580-332-5720
Mailing Address - Fax:580-332-5724
Practice Address - Street 1:1131 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4038
Practice Address - Country:US
Practice Address - Phone:580-332-5720
Practice Address - Fax:580-332-5724
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTRAL OKLAHOMA FAMILY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-20
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
OK23-61313336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234590AMedicaid
2138726OtherPK
2138726OtherPK