Provider Demographics
NPI:1326508706
Name:DEDMON PHARMACY INC
Entity Type:Organization
Organization Name:DEDMON PHARMACY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DEDMON
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:918-962-2131
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:SPIRO
Mailing Address - State:OK
Mailing Address - Zip Code:74959-0220
Mailing Address - Country:US
Mailing Address - Phone:918-962-2131
Mailing Address - Fax:
Practice Address - Street 1:213 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:SPIRO
Practice Address - State:OK
Practice Address - Zip Code:74959-2419
Practice Address - Country:US
Practice Address - Phone:918-962-2131
Practice Address - Fax:918-962-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100246960BMedicaid