Organization
THACKERVILLE PHARMACY
Active
Other names
Thackerville Pharmacy
Organization subpart
No
Provider details
NPI number
Authorized official
SUSAN SOUTH (MANAGER)
(580) 276-5161
Entity
Organization
Contact information
Practice address
11530 RIDGE RD STE 1, THACKERVILLE, OK 73459-9623
(580) 276-5161
(580) 276-9063
Mailing address
11530 RIDGE RD, SUITE 1, THACKERVILLE, OK 73459-9622
(580) 276-5161
(580) 276-9063
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
72-5917
OK
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200339440A
—
OK
01
—
2129291
PK
—
05
—
580121
—
TX
Enumeration date
01/18/2011
Last updated
03/06/2017
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