Organization
MATT'S COUNTRY BOY PHARMACY LLC
Active
Other names
country boy pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
MATT EVANS (PHARMACIST/OWNER)
(405) 390-3205
Entity
Organization
Contact information
Practice address
14890 SE 29TH ST STE 108, CHOCTAW, OK 73020-3516
(405) 390-3205
(405) 390-2516
Mailing address
14890 SE 29TH ST STE 108, CHOCTAW, OK 73020-3516
(405) 390-3205
(405) 390-2516
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
Primary
1-6052
OK
3336C0003X
Community/Retail Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200464490A
—
OK
01
—
2137264
PK
—
Enumeration date
10/05/2012
Last updated
08/25/2016
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