Organization
MANNFORD PHARMACY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIMBERLY JOANNA TILLEY DPH (PIC/OWNER)
(918) 865-7400
Entity
Organization
Contact information
Practice address
231 W TROWER BLVD, MANNFORD, OK 74044
(918) 865-7400
(918) 865-7411
Mailing address
PO BOX 267, MANNFORD, OK 74044-0267
(918) 865-7400
(918) 865-7411
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
11-8083
OK
3336C0003X
Community/Retail Pharmacy
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200750500A
—
OK
Enumeration date
12/19/2017
Last updated
12/07/2021
Update your record
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