Healthcare Provider Details

I. General information

NPI: 1871945162
Provider Name (Legal Business Name): MERCY HOSPITAL ARDMORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23223 RIGSBY RD
MADILL OK
73446-2327
US

IV. Provider business mailing address

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

V. Phone/Fax

Practice location:
  • Phone: 405-205-9301
  • Fax:
Mailing address:
  • Phone: 580-220-6226
  • Fax: 580-220-6110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number14328
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number14328
License Number StateOK

VIII. Authorized Official

Name: DR. MARK GLENN
Title or Position: DIRECTOR OF PHARMACY
Credential: PHARMD
Phone: 580-220-6226