Provider Demographics
NPI:1801936059
Name:TV DISCOUNT DRUG INC
Entity type:Organization
Organization Name:TV DISCOUNT DRUG INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN HORN
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-348-0220
Mailing Address - Street 1:112 W OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-3130
Mailing Address - Country:US
Mailing Address - Phone:405-282-2700
Mailing Address - Fax:405-282-4715
Practice Address - Street 1:112 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-3130
Practice Address - Country:US
Practice Address - Phone:405-282-2700
Practice Address - Fax:405-282-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK3232093336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100233220AMedicaid
2072797OtherPK
OK100233220AMedicaid