Provider Demographics
NPI:1649324880
Name:WESTVILLE PRESCRIPTION CENTER INC
Entity type:Organization
Organization Name:WESTVILLE PRESCRIPTION CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-723-5466
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:WESTVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74965-0405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 S WILLIAMS
Practice Address - Street 2:
Practice Address - City:WESTVILLE
Practice Address - State:OK
Practice Address - Zip Code:74965
Practice Address - Country:US
Practice Address - Phone:918-723-5466
Practice Address - Fax:918-723-4465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
OK46-42213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073339OtherPK
OK100238410AMedicaid
6508710001Medicare NSC