Organization
JACK JUSTICE
Active
Other names
Reavis Super Drug
Organization subpart
No
Provider details
NPI number
Authorized official
JULIE JUSTICE (AUTHORIZED OFFICIAL)
(405) 447-3911
Entity
Organization
Contact information
Practice address
110 A BURR AVE, PAULS VALLEY, OK 73075-1220
(405) 238-7391
(405) 238-7357
Mailing address
PO BOX 1220, PAULS VALLEY, OK 73075-2020
(405) 238-7391
(405) 238-1162
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
3336C0003X
Community/Retail Pharmacy
Primary
22-3755
OK
3336C0004X
Compounding Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100235750A
—
OK
01
—
2073053
PK
—
Enumeration date
07/01/2005
Last updated
10/28/2024
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