=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720171168
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHARMOLOGY BRISTOW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2006
-----------------------------------------------------
Last Update Date | 09/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E 7TH AVE
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74010-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-367-3328
-----------------------------------------------------
Fax | 918-367-2415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 E 7TH AVE
-----------------------------------------------------
City | BRISTOW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74010-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-367-3328
-----------------------------------------------------
Fax | 918-367-2415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICER
-----------------------------------------------------
Name | MATTHEW FIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-261-3048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 11-5374
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------