Provider Demographics
NPI:1326443565
Name:JANE PHILLIPS MEMORIAL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:JANE PHILLIPS MEMORIAL MEDICAL CENTER INC
Other - Org Name:JANE PHILLIPS MEDCARE AMBULATORY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-331-1550
Mailing Address - Street 1:3500 E FRANK PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2411
Mailing Address - Country:US
Mailing Address - Phone:918-331-1540
Mailing Address - Fax:
Practice Address - Street 1:3500 E FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2411
Practice Address - Country:US
Practice Address - Phone:918-331-1540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
OK969643336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699490 LMedicaid
OK100699490 B DMEMedicaid
2148573OtherPK
OK100699490 B DMEMedicaid