| Organization Name: | MATTS COUNTRY BOY PHARMACY LLC |
| NPI Number: | 1164774709 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MATT EVANS (PHARMACIST/OWNER) |
| Mailing Address: | 14890 Se 29th St Ste 108 Choctaw |
| State: | OK US |
| Postal Code: | 730203516 |
| Phone Number: | 4053903205 |
| Fax Number: | 4053902516 |
| NPI Enumeration Date: | 10/05/2012 |
| NPI Last Update Date: | 07/02/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 3336L0003X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Pharmacy |
| Taxonomy Specialization: | Long Term Care Pharmacy |
| Taxonomy Definition: | A pharmacy that dispenses medicinal preparations delivered to patients residing within an intermediate or skilled nursing facility, including intermediate care facilities for mentally retarded, hospice, assisted living facilities, group homes, and other forms of congregate living arrangements. |