Provider Demographics
NPI:1023004215
Name:HUTTON PHARMACY INC
Entity Type:Organization
Organization Name:HUTTON PHARMACY INC
Other - Org Name:HUTTON PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:HUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-363-2137
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:BLACKWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74631-0110
Mailing Address - Country:US
Mailing Address - Phone:580-363-2137
Mailing Address - Fax:580-363-5582
Practice Address - Street 1:119 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BLACKWELL
Practice Address - State:OK
Practice Address - Zip Code:74631-2226
Practice Address - Country:US
Practice Address - Phone:580-363-2137
Practice Address - Fax:580-363-5582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK617433336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2072648OtherPK
OK100233110AMedicaid
OK90003904315Medicaid
0614960001Medicare NSC