Provider Demographics
NPI:1093725285
Name:HENRY ROBERTS EXPRESS PHARMACY LLC
Entity Type:Organization
Organization Name:HENRY ROBERTS EXPRESS PHARMACY LLC
Other - Org Name:HENRY ROBERTS EXPRESS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:580-223-5828
Mailing Address - Street 1:1316 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1285
Mailing Address - Country:US
Mailing Address - Phone:580-223-5828
Mailing Address - Fax:580-226-3902
Practice Address - Street 1:1316 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1285
Practice Address - Country:US
Practice Address - Phone:580-223-5828
Practice Address - Fax:580-226-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X, 3336H0001X, 3336L0003X
OK12-56533336C0003X
OK12-41843336M0002X, 3336S0011X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2076065OtherPK
OK100244950AMedicaid
OK100244950BMedicaid
OK100244950AMedicaid