1578656732 NPI number — BROADWAY CORNER DRUG

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 1578656732 NPI number — BROADWAY CORNER DRUG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROADWAY CORNER DRUG
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:
Provider Other Organization Name Type Code:
6
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:
1578656732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1469
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MULDROW
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74948-1469
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:
101 E SHAWNTEL SMITH BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MULDROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74948
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-427-1985
Provider Business Practice Location Address Fax Number:
918-427-1157
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOMBS
Authorized Official First Name:
RHONDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CO OWNER DR OF PHY
Authorized Official Telephone Number:
918-427-1985

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 34-3763 , 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: 100242810A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2074693 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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