Provider Demographics
NPI:1609963800
Name:STATE OF OKLAHOMA DEPT. OF HUMAN SERVICES
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA DEPT. OF HUMAN SERVICES
Other - Org Name:SOUTHERN OKLAHOMA RESOURCE CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAMS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-521-3565
Mailing Address - Street 1:RT 1 BOX 44A
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075
Mailing Address - Country:US
Mailing Address - Phone:405-238-6401
Mailing Address - Fax:
Practice Address - Street 1:RT 1 BOX 44A
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075
Practice Address - Country:US
Practice Address - Phone:405-238-6401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy