Provider Demographics
NPI:1700961091
Name:HARRISON DISCOUNT PHARMACY PLLC
Entity Type:Organization
Organization Name:HARRISON DISCOUNT PHARMACY PLLC
Other - Org Name:HARRISON DISCOUNT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-273-9906
Mailing Address - Street 1:1442 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-5208
Mailing Address - Country:US
Mailing Address - Phone:405-273-9906
Mailing Address - Fax:405-273-4329
Practice Address - Street 1:1442 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5208
Practice Address - Country:US
Practice Address - Phone:405-273-9906
Practice Address - Fax:405-273-4329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OK1047283336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100239400AMedicaid
2074147OtherPK
5321990001Medicare NSC