Healthcare Provider Details

I. General information

NPI: 1326422957
Provider Name (Legal Business Name): OU BEDLAM CHARITABLE PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1111 S SAINT LOUIS AVE
TULSA OK
74120-5440
US

IV. Provider business mailing address

1111 S SAINT LOUIS AVE
TULSA OK
74120-5440
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4704
  • Fax:
Mailing address:
  • Phone: 918-619-4704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number2-6704
License Number StateOK

VIII. Authorized Official

Name: KIMBERLY CROSBY
Title or Position: PHARMACIST-IN-CHARGE
Credential:
Phone: 918-660-3588