Provider Demographics
NPI:1356487912
Name:MICHAEL C DODD AND WILMAN C
Entity Type:Organization
Organization Name:MICHAEL C DODD AND WILMAN C
Other - Org Name:VIAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GEN PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DODD
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:718-773-8111
Mailing Address - Street 1:PO BOX 465
Mailing Address - Street 2:
Mailing Address - City:VIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74962-0465
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 THORTON ST
Practice Address - Street 2:
Practice Address - City:VIAN
Practice Address - State:OK
Practice Address - Zip Code:74962
Practice Address - Country:US
Practice Address - Phone:918-773-8111
Practice Address - Fax:918-773-5110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
OK3421253336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3708471OtherOTHER ID NUMBER-COMMERCIAL NUMBER
3708471OtherOTHER ID NUMBER