=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659451953
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARM BLANCHARD ACQUISITION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 09/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 NE 10TH ST
-----------------------------------------------------
City | BLANCHARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73010-9817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-485-9311
-----------------------------------------------------
Fax | 405-485-9312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2090 301 NE 10TH STREET
-----------------------------------------------------
City | BLANCHARD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73010-2090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-485-9311
-----------------------------------------------------
Fax | 405-485-9312
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | MATTHEW FINN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-261-3048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 47-7319
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------