Provider Demographics
NPI:1043384431
Name:LAVERNE PHARMACY MANAGEMENT INC
Entity Type:Organization
Organization Name:LAVERNE PHARMACY MANAGEMENT INC
Other - Org Name:MEDIC PHARMACY & GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:580-921-3373
Mailing Address - Street 1:PO BOX 1250
Mailing Address - Street 2:
Mailing Address - City:LAVERNE
Mailing Address - State:OK
Mailing Address - Zip Code:73848-1250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:102 W JANE JAYROE
Practice Address - Street 2:
Practice Address - City:LAVERNE
Practice Address - State:OK
Practice Address - Zip Code:73848-1250
Practice Address - Country:US
Practice Address - Phone:580-921-3373
Practice Address - Fax:580-921-5469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336L0003X
OK7151263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100810930BMedicaid
2074719OtherPK
1016790001Medicare PIN