Provider Demographics
NPI:1104031962
Name:MCBRIDE CLINIC ORTHOPEDIC HOSPITAL LLC
Entity Type:Organization
Organization Name:MCBRIDE CLINIC ORTHOPEDIC HOSPITAL LLC
Other - Org Name:MCBRIDE ORTHOPEDIC HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-486-2191
Mailing Address - Street 1:9600 BROADWAY EXT
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73114-7408
Mailing Address - Country:US
Mailing Address - Phone:405-486-2184
Mailing Address - Fax:405-486-2188
Practice Address - Street 1:9600 BROADWAY EXT
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73114-7408
Practice Address - Country:US
Practice Address - Phone:405-486-2184
Practice Address - Fax:405-486-2188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336S0011X
OK1-55533336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069370LMedicaid
2077051OtherPK
OK200069370AMedicaid