Healthcare Provider Details

I. General information

NPI: 1235112699
Provider Name (Legal Business Name): LARRY R DISMORE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2005
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 E ST
SNYDER OK
73566-1850
US

IV. Provider business mailing address

PO BOX 344
SNYDER OK
73566-0344
US

V. Phone/Fax

Practice location:
  • Phone: 580-569-2008
  • Fax: 580-569-4929
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number41-2210
License Number StateOK

VIII. Authorized Official

Name: LARRY DISMONE
Title or Position: OWNER AND PHRMCST
Credential: DPH
Phone: 580-569-2008