Provider Demographics
NPI:1295832558
Name:OLE MINERS PHARMACY
Entity type:Organization
Organization Name:OLE MINERS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LINDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST
Authorized Official - Phone:918-673-1552
Mailing Address - Street 1:103 S CONNELL AVE
Mailing Address - Street 2:
Mailing Address - City:PICHER
Mailing Address - State:OK
Mailing Address - Zip Code:74360-1533
Mailing Address - Country:US
Mailing Address - Phone:918-673-1552
Mailing Address - Fax:918-673-2050
Practice Address - Street 1:103 S CONNELL AVE
Practice Address - Street 2:
Practice Address - City:PICHER
Practice Address - State:OK
Practice Address - Zip Code:74360-0248
Practice Address - Country:US
Practice Address - Phone:918-673-1552
Practice Address - Fax:918-673-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100443320AOtherMEDICAID
OK100245160AMedicaid
KS100443320AOtherMEDICAID