Provider Demographics
NPI:1235112699
Name:LARRY R DISMORE
Entity Type:Organization
Organization Name:LARRY R DISMORE
Other - Org Name:LARRYS REXALL DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHRMCST
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DISMONE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-569-2008
Mailing Address - Street 1:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:SNYDER
Mailing Address - State:OK
Mailing Address - Zip Code:73566-0344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:616 E ST
Practice Address - Street 2:
Practice Address - City:SNYDER
Practice Address - State:OK
Practice Address - Zip Code:73566-1850
Practice Address - Country:US
Practice Address - Phone:580-569-2008
Practice Address - Fax:580-569-4929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK41-22103336C0003X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235810AMedicaid
2073255OtherPK
OK90003914728Medicaid