Provider Demographics
NPI:1669576625
Name:THOMAS WILSON PHARMACY INC
Entity type:Organization
Organization Name:THOMAS WILSON PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:MATLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-737-3464
Mailing Address - Street 1:911 S AIR DEPOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4836
Mailing Address - Country:US
Mailing Address - Phone:405-737-3464
Mailing Address - Fax:405-737-9554
Practice Address - Street 1:911 S AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4836
Practice Address - Country:US
Practice Address - Phone:405-737-3464
Practice Address - Fax:405-737-9554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OK1-72803336C0003X, 3336C0003X
OK172803336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234270BMedicaid
OK100234270AMedicaid
2081553OtherPK
OK100804970AMedicaid