Provider Demographics
NPI:1801885041
Name:LANGSTON DRUG STORE, INC.
Entity type:Organization
Organization Name:LANGSTON DRUG STORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:MILLER-MORRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-678-4136
Mailing Address - Street 1:124 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:MO
Mailing Address - Zip Code:65605-1427
Mailing Address - Country:US
Mailing Address - Phone:417-678-4136
Mailing Address - Fax:417-678-2014
Practice Address - Street 1:1202 MAIN ST
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-4555
Practice Address - Country:US
Practice Address - Phone:479-474-3431
Practice Address - Fax:479-474-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR203823336L0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139920718Medicaid
AR0400678OtherNCPDP
OK100246160AMedicaid
AR101120407Medicaid
OK100246160AMedicaid