Healthcare Provider Details

I. General information

NPI: 1609938349
Provider Name (Legal Business Name): E D ALLENS PHARMACY OF BROKEN BOW INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S PARK DR
BROKEN BOW OK
74728-5331
US

IV. Provider business mailing address

619 S PARK DR
BROKEN BOW OK
74728-5331
US

V. Phone/Fax

Practice location:
  • Phone: 580-584-5841
  • Fax: 580-584-5845
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number255237
License Number StateOK

VIII. Authorized Official

Name: EDDIE ALLEN
Title or Position: MANAGER
Credential:
Phone: 580-584-5841