Provider Demographics
NPI:1295318418
Name:CARL'S HOMETOWN PHARMACY LLC
Entity type:Organization
Organization Name:CARL'S HOMETOWN PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST918
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:CARMON
Authorized Official - Last Name:DEASON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:918-791-3295
Mailing Address - Street 1:PO BOX 451689
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-1689
Mailing Address - Country:US
Mailing Address - Phone:918-791-3295
Mailing Address - Fax:918-791-3296
Practice Address - Street 1:1101 NEO LOOP
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344
Practice Address - Country:US
Practice Address - Phone:918-791-3295
Practice Address - Fax:918-791-3296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK45-8920OtherSTATE PHARMACY LICENSE
OK200983770AMedicaid