Provider Demographics
NPI:1447011135
Name:EAGLET PHARMACY LLC
Entity type:Organization
Organization Name:EAGLET PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VALIMOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:PANARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-676-5300
Mailing Address - Street 1:2209 SW 104TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7551
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2209 SW 104TH ST STE E
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7551
Practice Address - Country:US
Practice Address - Phone:405-676-5300
Practice Address - Fax:405-676-5321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201224190AMedicaid
OK1-9605OtherBOARD OF PHARMACY