Provider Demographics
NPI:1336185222
Name:COLLINSVILLE FAMILY PHARMACY LC
Entity Type:Organization
Organization Name:COLLINSVILLE FAMILY PHARMACY LC
Other - Org Name:COLLINSVILLE FAMILY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLTON
Authorized Official - Middle Name:B
Authorized Official - Last Name:TURNBULL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-371-2547
Mailing Address - Street 1:1205 W MAIN ST STE A
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3114
Mailing Address - Country:US
Mailing Address - Phone:918-371-2547
Mailing Address - Fax:918-371-0268
Practice Address - Street 1:1205 W MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3114
Practice Address - Country:US
Practice Address - Phone:918-371-2547
Practice Address - Fax:918-371-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OK263883336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2081529OtherPK
OK100807920BMedicaid
OK100807920AMedicaid
OK100807920BMedicaid