Provider Demographics
NPI:1518028380
Name:JACKSON COUNTY MEMORIAL HOSP PHCY
Entity Type:Organization
Organization Name:JACKSON COUNTY MEMORIAL HOSP PHCY
Other - Org Name:JACKSON COUNTY MEMORIAL HOSPITAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY
Authorized Official - Prefix:
Authorized Official - First Name:RETA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-379-5708
Mailing Address - Street 1:PO BOX 8190
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73522-8190
Mailing Address - Country:US
Mailing Address - Phone:580-379-5700
Mailing Address - Fax:580-379-5709
Practice Address - Street 1:1200 E PECAN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-6141
Practice Address - Country:US
Practice Address - Phone:580-379-5700
Practice Address - Fax:580-379-5709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1712593336I0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2072621OtherPK