Provider Demographics
NPI:1992828776
Name:UNITED DISCOUNT DRUG OF GUYMON, INC.
Entity Type:Organization
Organization Name:UNITED DISCOUNT DRUG OF GUYMON, INC.
Other - Org Name:UNITED DISCOUNT DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-338-8421
Mailing Address - Street 1:PO BOX 1131
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-1131
Mailing Address - Country:US
Mailing Address - Phone:580-338-8421
Mailing Address - Fax:580-338-0721
Practice Address - Street 1:1902 N. ACADEMY STREET
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942
Practice Address - Country:US
Practice Address - Phone:580-338-8421
Practice Address - Fax:580-338-0721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK43-1959332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK3710022OtherNCPDP