Healthcare Provider Details

I. General information

NPI: 1629602651
Provider Name (Legal Business Name): HENRYETTA DRUG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2020
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 W MAIN ST
HENRYETTA OK
74437-4245
US

IV. Provider business mailing address

744 S MISSISSIPPI AVE
ATOKA OK
74525-3355
US

V. Phone/Fax

Practice location:
  • Phone: 918-652-3361
  • Fax: 918-652-9554
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: RYAN JAY RITTER
Title or Position: MANAGER
Credential:
Phone: 580-889-0230