Provider Demographics
NPI:1144328956
Name:MEDICINE CHEST PHARMACY CO
Entity type:Organization
Organization Name:MEDICINE CHEST PHARMACY CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES & OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLARD
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:HOLSTED
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-262-1835
Mailing Address - Street 1:201 S BICKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:EL RENO
Mailing Address - State:OK
Mailing Address - Zip Code:73036-5600
Mailing Address - Country:US
Mailing Address - Phone:405-262-1222
Mailing Address - Fax:405-262-0033
Practice Address - Street 1:201 S BICKFORD AVE
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036-5600
Practice Address - Country:US
Practice Address - Phone:405-262-1222
Practice Address - Fax:405-262-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOKLA7497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1144328956Medicare NSC
OK0693450001Medicare ID - Type Unspecified