Active NPI
Mitchell Ally Wallis
- Pharmacist
- Broken Bow, OK
National Provider Identifier
1528925104
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 21050
- Practice address
- 802 N Park Dr
Broken Bow, OK 74728-2146 - Phone
- (580) 584-2850
- Fax
- (580) 584-2820
- NPI assigned
- Jan 6, 2026
- Last updated
- Jan 6, 2026
- Sex
- Unspecified or another gender identity
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 21050 | OK | Primary |
Addresses
Primary practice location
802 N Park Dr
Broken Bow, OK 74728-2146
Mailing address
104 W Sherry LN
Broken Bow, OK 74728-1726
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 21050 | OK | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Simpson Pharmacy, PLLC | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1767657600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1767657600000",
"number": "1528925104",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "104 W SHERRY LN",
"city": "BROKEN BOW",
"state": "OK",
"postal_code": "747281726"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "802 N PARK DR",
"city": "BROKEN BOW",
"state": "OK",
"postal_code": "747282146",
"telephone_number": "580-584-2850",
"fax_number": "580-584-2820"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLIS",
"first_name": "MITCHELL",
"middle_name": "ALLY",
"sole_proprietor": "YES",
"sex": "X",
"enumeration_date": "2026-01-06",
"last_updated": "2026-01-06",
"certification_date": "2026-01-06",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "",
"desc": "Pharmacist",
"state": "OK",
"license": "21050",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Broken Bow, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.