Healthcare Provider Details

I. General information

NPI: 1720171168
Provider Name (Legal Business Name): PHARMOLOGY BRISTOW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 09/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E 7TH AVE
BRISTOW OK
74010-2503
US

IV. Provider business mailing address

201 E 7TH AVE
BRISTOW OK
74010-2503
US

V. Phone/Fax

Practice location:
  • Phone: 918-367-3328
  • Fax: 918-367-2415
Mailing address:
  • Phone: 918-367-3328
  • Fax: 918-367-2415

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11-5374
License Number StateOK

VIII. Authorized Official

Name: MATTHEW FIN
Title or Position: OFFICER
Credential:
Phone: 469-261-3048