1760810071 NPI number — BROOKHAVEN SPECIALTY PHARMACY LLC

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 1760810071 NPI number — BROOKHAVEN SPECIALTY PHARMACY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROOKHAVEN SPECIALTY PHARMACY LLC
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:
1760810071
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5874 S MINGO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74146-6425
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-695-0167
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3750 W ROBINSON ST
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
NORMAN
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73072-3660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-421-6929
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
KRISTY
Authorized Official Middle Name:
LAUREN
Authorized Official Title or Position:
PHARMACIST/PIC
Authorized Official Telephone Number:
405-801-4100

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  7-6445 , 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)





Copyright © 2007-2025 www.npivalidator.com