Provider Demographics
NPI:1336257146
Name:DICUS THRIF-T-WISE PHARMACY, INC.
Entity Type:Organization
Organization Name:DICUS THRIF-T-WISE PHARMACY, INC.
Other - Org Name:DICUS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACY
Authorized Official - Phone:580-332-8888
Mailing Address - Street 1:312 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-6406
Mailing Address - Country:US
Mailing Address - Phone:580-332-8888
Mailing Address - Fax:580-332-7965
Practice Address - Street 1:312 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6406
Practice Address - Country:US
Practice Address - Phone:580-332-8888
Practice Address - Fax:580-332-7965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK239483336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2072612OtherPK
OK100232570AMedicaid