Provider Demographics
NPI:1649363086
Name:CITYRX LLC
Entity type:Organization
Organization Name:CITYRX LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-623-4545
Mailing Address - Street 1:101 N CLARENCE NASH BLVD
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-4250
Mailing Address - Country:US
Mailing Address - Phone:580-623-4545
Mailing Address - Fax:
Practice Address - Street 1:101 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-4250
Practice Address - Country:US
Practice Address - Phone:580-623-4545
Practice Address - Fax:580-623-4549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0003X
OK4935243336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100241610AMedicaid
2073332OtherPK