Healthcare Provider Details

I. General information

NPI: 1891870184
Provider Name (Legal Business Name): DAVENPORT HEALTH HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5310 E HIGHWAY 37
TUTTLE OK
73089
US

IV. Provider business mailing address

5310 E HIGHWAY 37
TUTTLE OK
73089
US

V. Phone/Fax

Practice location:
  • Phone: 405-381-4425
  • Fax: 405-381-4426
Mailing address:
  • Phone: 405-381-4425
  • Fax: 405-381-4426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number18-2672
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100238340A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier2073923
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: JOEL P DAVENPORT
Title or Position: OWNER/PHARMACIST IN CHARGE
Credential: PHARMD
Phone: 405-248-8455