Healthcare Provider Details

I. General information

NPI: 1306909916
Provider Name (Legal Business Name): BALTRO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 07/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 COONROD AVE
MANNFORD OK
74044-3290
US

IV. Provider business mailing address

5828 S 170TH WEST AVE
SAND SPRINGS OK
74063-2312
US

V. Phone/Fax

Practice location:
  • Phone: 918-865-2164
  • Fax: 918-865-7933
Mailing address:
  • Phone: 918-245-3791
  • Fax: 918-245-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11-6040
License Number StateOK

VIII. Authorized Official

Name: WILLIE HIGGINS
Title or Position: OWNER/PHARMACIST
Credential:
Phone: 918-245-3791