Provider Demographics
NPI:1972657930
Name:BENNETT DRUG INC
Entity Type:Organization
Organization Name:BENNETT DRUG INC
Other - Org Name:LIBERTY DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-654-1111
Mailing Address - Street 1:15 WEST MAIN ST
Mailing Address - Street 2:PO BOX 362
Mailing Address - City:CARNEGIE
Mailing Address - State:OK
Mailing Address - Zip Code:73015-0362
Mailing Address - Country:US
Mailing Address - Phone:580-654-1111
Mailing Address - Fax:580-654-1229
Practice Address - Street 1:15 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:CARNEGIE
Practice Address - State:OK
Practice Address - Zip Code:73015-0362
Practice Address - Country:US
Practice Address - Phone:580-654-1111
Practice Address - Fax:580-654-1229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK202419332B00000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1002366700BMedicaid
OK0180560001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #