Provider Demographics
NPI:1275033474
Name:ELGIN PHARMACY, LLC
Entity Type:Organization
Organization Name:ELGIN PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENDAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:580-492-5007
Mailing Address - Street 1:7523 US HIGHWAY 277
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:OK
Mailing Address - Zip Code:73538-2161
Mailing Address - Country:US
Mailing Address - Phone:580-492-5007
Mailing Address - Fax:580-492-5090
Practice Address - Street 1:7523 US HIGHWAY 277
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:OK
Practice Address - Zip Code:73538-2161
Practice Address - Country:US
Practice Address - Phone:580-492-5007
Practice Address - Fax:580-492-5090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3-51523336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200757190AMedicaid