Provider Demographics
NPI:1245236462
Name:BTBKMK LLC
Entity Type:Organization
Organization Name:BTBKMK LLC
Other - Org Name:OLEXY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-562-2626
Mailing Address - Street 1:143 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:PA
Mailing Address - Zip Code:18517-1415
Mailing Address - Country:US
Mailing Address - Phone:570-562-2626
Mailing Address - Fax:717-562-2635
Practice Address - Street 1:143 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:PA
Practice Address - Zip Code:18517-1415
Practice Address - Country:US
Practice Address - Phone:570-562-2626
Practice Address - Fax:717-562-2635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-22
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
PAPP410613L3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01970591Medicaid
2081318OtherPK
PA01970591Medicaid