Provider Demographics
NPI:1780767731
Name:PALACE DRUG OF COALGATE LLC
Entity type:Organization
Organization Name:PALACE DRUG OF COALGATE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-927-2064
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-0273
Mailing Address - Country:US
Mailing Address - Phone:580-927-2064
Mailing Address - Fax:580-927-2508
Practice Address - Street 1:104 W OHIO AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-2827
Practice Address - Country:US
Practice Address - Phone:580-927-2064
Practice Address - Fax:580-927-2508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
OK74-76903336C0003X
OK74-38613336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100233410AMedicaid
2072710OtherPK