Healthcare Provider Details

I. General information

NPI: 1861585291
Provider Name (Legal Business Name): BUNKER HILL PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 11/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 N MAIN ST
ALTUS OK
73521-2145
US

IV. Provider business mailing address

1610 N MAIN ST
ALTUS OK
73521-2145
US

V. Phone/Fax

Practice location:
  • Phone: 580-482-7530
  • Fax: 580-482-9139
Mailing address:
  • Phone: 580-482-7530
  • Fax: 580-482-9139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number17-5510
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MARK DODSON
Title or Position: PHARMACIST
Credential:
Phone: 580-482-7530