Provider Demographics
NPI:1295804920
Name:GRANITE DRUG, INC
Entity type:Organization
Organization Name:GRANITE DRUG, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARM IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:LIONEL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROSS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-535-2130
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:
Mailing Address - City:GRANITE
Mailing Address - State:OK
Mailing Address - Zip Code:73547-0158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:580-535-2001
Practice Address - Street 1:316 MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANITE
Practice Address - State:OK
Practice Address - Zip Code:73547-0158
Practice Address - Country:US
Practice Address - Phone:580-535-2130
Practice Address - Fax:580-535-2001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X, 3336M0002X
OK6017293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232860AMedicaid
2072794OtherPK