Healthcare Provider Details

I. General information

NPI: 1124128962
Provider Name (Legal Business Name): MEDICAL PARK CENTER PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 12/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 E FRANK PHILLIPS BLVD STE 203
BARTLESVILLE OK
74006-2495
US

IV. Provider business mailing address

3400 E FRANK PHILLIPS BLVD STE 203
BARTLESVILLE OK
74006-2495
US

V. Phone/Fax

Practice location:
  • Phone: 918-331-2525
  • Fax: 918-331-2589
Mailing address:
  • Phone: 918-331-2525
  • Fax: 918-331-2589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number9-2507
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: BRENT MOORE
Title or Position: OWNER
Credential: DPH
Phone: 918-331-2525