Healthcare Provider Details

I. General information

NPI: 1275762932
Provider Name (Legal Business Name): NEWBERRY EXPRESS PHARMACY-CLINICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2009
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S BROADWAY ST
MARLOW OK
73055-3433
US

IV. Provider business mailing address

801 S BROADWAY ST
MARLOW OK
73055-3433
US

V. Phone/Fax

Practice location:
  • Phone: 580-658-3784
  • Fax: 580-658-3725
Mailing address:
  • Phone: 580-658-3784
  • Fax: 580-658-3725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code333600000X
TaxonomyPharmacy
License Number13-4170
License Number StateOK

VIII. Authorized Official

Name: GARY NEWBERRY
Title or Position: OWNER
Credential: D.PH.
Phone: 580-658-6784