Provider Demographics
NPI:1700509544
Name:R&S DRUG STORE #1 LLC
Entity Type:Organization
Organization Name:R&S DRUG STORE #1 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLEE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KERN
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-255-6292
Mailing Address - Street 1:821 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-4615
Mailing Address - Country:US
Mailing Address - Phone:580-255-6292
Mailing Address - Fax:580-255-6293
Practice Address - Street 1:821 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-4615
Practice Address - Country:US
Practice Address - Phone:580-255-6292
Practice Address - Fax:580-255-6293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200686130AMedicaid