Provider Demographics
NPI:1881019479
Name:HENDERSON, BRUCE
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8053 W COUNTY ROAD 76
Mailing Address - Street 2:
Mailing Address - City:GUTHRIE
Mailing Address - State:OK
Mailing Address - Zip Code:73044-9574
Mailing Address - Country:US
Mailing Address - Phone:405-969-3817
Mailing Address - Fax:
Practice Address - Street 1:8053 W COUNTY ROAD 76
Practice Address - Street 2:
Practice Address - City:GUTHRIE
Practice Address - State:OK
Practice Address - Zip Code:73044-9574
Practice Address - Country:US
Practice Address - Phone:405-969-3817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR11444183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist