Provider Demographics
NPI:1578656732
Name:BROADWAY CORNER DRUG
Entity Type:Organization
Organization Name:BROADWAY CORNER DRUG
Other - Org Name:BROADWAY CORNER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO OWNER DR OF PHY
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-427-1985
Mailing Address - Street 1:PO BOX 1469
Mailing Address - Street 2:
Mailing Address - City:MULDROW
Mailing Address - State:OK
Mailing Address - Zip Code:74948-1469
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 E SHAWNTEL SMITH BLVD
Practice Address - Street 2:
Practice Address - City:MULDROW
Practice Address - State:OK
Practice Address - Zip Code:74948
Practice Address - Country:US
Practice Address - Phone:918-427-1985
Practice Address - Fax:918-427-1157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK34-37633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100242810AMedicaid
2074693OtherPK