Healthcare Provider Details

I. General information

NPI: 1164501433
Provider Name (Legal Business Name): BRADLEY PAUL BANISTER PHARM. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S. LOUIS TITTLE
MANGUM OK
73554
US

IV. Provider business mailing address

403 S ROBINSON AVE
MANGUM OK
73554-4613
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-5400
  • Fax: 580-782-5404
Mailing address:
  • Phone: 580-782-2750
  • Fax: 580-782-5404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13420
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: