Provider Demographics
NPI:1275779159
Name:FAIRVIEW RX INC
Entity Type:Organization
Organization Name:FAIRVIEW RX INC
Other - Org Name:FAIRVIEW RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DOCTOR OF PHARM
Authorized Official - Phone:580-227-2045
Mailing Address - Street 1:210 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OK
Mailing Address - Zip Code:73737-1326
Mailing Address - Country:US
Mailing Address - Phone:580-227-2045
Mailing Address - Fax:580-227-2046
Practice Address - Street 1:210 E STATE RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OK
Practice Address - Zip Code:73737-1326
Practice Address - Country:US
Practice Address - Phone:580-227-2045
Practice Address - Fax:580-227-2046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-26
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
OK6653553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200235550AMedicaid
2118447OtherPK
OK200235550BMedicaid
OK200235550BMedicaid