Healthcare Provider Details

I. General information

NPI: 1750527925
Provider Name (Legal Business Name): HENRY ROBERTS EXPRESS PHARMACY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 12/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1306 12TH AVE NW
ARDMORE OK
73401-1285
US

IV. Provider business mailing address

1306 12TH AVE NW
ARDMORE OK
73401-1285
US

V. Phone/Fax

Practice location:
  • Phone: 580-226-2684
  • Fax: 580-226-3902
Mailing address:
  • Phone: 580-226-2684
  • Fax: 580-226-3902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number12-4184
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number12-4184
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number12-4184
License Number StateOK

VIII. Authorized Official

Name: HENRY ROBERTS
Title or Position: OWNER
Credential:
Phone: 580-226-2684