Provider Demographics
NPI:1275762932
Name:NEWBERRY EXPRESS PHARMACY-CLINICAL SERVICES
Entity Type:Organization
Organization Name:NEWBERRY EXPRESS PHARMACY-CLINICAL SERVICES
Other - Org Name:NEWBERRY EXPRESS PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-658-6784
Mailing Address - Street 1:801 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:MARLOW
Mailing Address - State:OK
Mailing Address - Zip Code:73055-3433
Mailing Address - Country:US
Mailing Address - Phone:580-658-3784
Mailing Address - Fax:580-658-3725
Practice Address - Street 1:801 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MARLOW
Practice Address - State:OK
Practice Address - Zip Code:73055-3433
Practice Address - Country:US
Practice Address - Phone:580-658-3784
Practice Address - Fax:580-658-3725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-02
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13-4170333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100244800AMedicaid