Provider Demographics
NPI:1972674141
Name:SOUTHERN OKLAHOMA MENTAL HEALTH AND INSTITUTIONAL PHARMACY
Entity Type:Organization
Organization Name:SOUTHERN OKLAHOMA MENTAL HEALTH AND INSTITUTIONAL PHARMACY
Other - Org Name:HEALTHCARE PHARMACY OF OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-238-7391
Mailing Address - Street 1:110 BURR AVE
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-3848
Mailing Address - Country:US
Mailing Address - Phone:405-238-7391
Mailing Address - Fax:405-238-7357
Practice Address - Street 1:110 BURR AVE
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-3848
Practice Address - Country:US
Practice Address - Phone:405-238-7391
Practice Address - Fax:405-238-7357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2250383336L0003X, 3336M0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Not Answered3336M0002XSuppliersPharmacyMail Order Pharmacy
Not Answered3336S0011XSuppliersPharmacySpecialty Pharmacy