Provider Demographics
NPI:1336287325
Name:CONSUMERS IGA PHARMACY
Entity Type:Organization
Organization Name:CONSUMERS IGA PHARMACY
Other - Org Name:CONSUMERS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARIBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:EADES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-372-5242
Mailing Address - Street 1:909 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-4302
Mailing Address - Country:US
Mailing Address - Phone:405-372-5242
Mailing Address - Fax:405-372-2831
Practice Address - Street 1:909 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4302
Practice Address - Country:US
Practice Address - Phone:405-372-5242
Practice Address - Fax:405-372-2831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK838093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100244650AMedicaid
2074705OtherPK
3719385OtherOTHER ID NUMBER-COMMERCIAL NUMBER