Provider Demographics
NPI:1134545999
Name:OLIVERS EXPRESS PHARMACY LLC
Entity type:Organization
Organization Name:OLIVERS EXPRESS PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:LACKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:580-744-1401
Mailing Address - Street 1:PO BOX 250
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-0250
Mailing Address - Country:US
Mailing Address - Phone:580-227-4000
Mailing Address - Fax:580-227-4003
Practice Address - Street 1:624 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-1216
Practice Address - Country:US
Practice Address - Phone:580-227-4000
Practice Address - Fax:580-227-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200531040AMedicaid