1609938349 NPI number — E D ALLENS PHARMACY OF BROKEN BOW INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609938349 NPI number — E D ALLENS PHARMACY OF BROKEN BOW INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
E D ALLENS PHARMACY OF BROKEN BOW INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
EDDIE ALLENS PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609938349
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
619 S PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROKEN BOW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74728-5331
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
619 S PARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROKEN BOW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74728-5331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-584-5841
Provider Business Practice Location Address Fax Number:
580-584-5845
Provider Enumeration Date:
12/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
580-584-5841

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  255237 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100237740A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2073473 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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