Basic Information
| Provider Information | |||||||||
| NPI: | 1831689397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VARIETY CARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VARIETY CARE PHARMACY #721 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 721 W BRITTON RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731142909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | 4056326688 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 W BRITTON RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731142909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056326688 | ||||||||
| FaxNumber: | 4056326688 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2018 | ||||||||
| LastUpdateDate: | 05/10/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PHAN | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PHARMACY | ||||||||
| AuthorizedOfficialTelephone: | 4056326688 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | 1-8187 | OK | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 2176779 | 01 | PK | OTHER |