Provider Demographics
NPI:1649336520
Name:CHOTEAU DISCOUNT PHARMACY INC
Entity type:Organization
Organization Name:CHOTEAU DISCOUNT PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-476-6455
Mailing Address - Street 1:PO BOX 700
Mailing Address - Street 2:
Mailing Address - City:INOLA
Mailing Address - State:OK
Mailing Address - Zip Code:74036-0700
Mailing Address - Country:US
Mailing Address - Phone:918-476-6455
Mailing Address - Fax:918-476-6966
Practice Address - Street 1:214 N CHOUTEAU AVE
Practice Address - Street 2:
Practice Address - City:CHOUTEAU
Practice Address - State:OK
Practice Address - Zip Code:74337-3242
Practice Address - Country:US
Practice Address - Phone:918-476-6455
Practice Address - Fax:918-476-6966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK30-45643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100246450AMedicaid
2076375OtherPK