Healthcare Provider Details

I. General information

NPI: 1518028380
Provider Name (Legal Business Name): JACKSON COUNTY MEMORIAL HOSP PHCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E PECAN ST
ALTUS OK
73521-6141
US

IV. Provider business mailing address

PO BOX 8190
ALTUS OK
73522-8190
US

V. Phone/Fax

Practice location:
  • Phone: 580-379-5700
  • Fax: 580-379-5709
Mailing address:
  • Phone: 580-379-5700
  • Fax: 580-379-5709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number171259
License Number StateOK

VIII. Authorized Official

Name: RETA BENNETT
Title or Position: DIR OF PHCY
Credential: DPH
Phone: 580-379-5708