Provider Demographics
NPI:1124128962
Name:MEDICAL PARK CENTER PHARMACY INC
Entity type:Organization
Organization Name:MEDICAL PARK CENTER PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-331-2525
Mailing Address - Street 1:3400 E FRANK PHILLIPS BLVD
Mailing Address - Street 2:STE 203
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2495
Mailing Address - Country:US
Mailing Address - Phone:918-331-2525
Mailing Address - Fax:918-331-2589
Practice Address - Street 1:3400 E FRANK PHILLIPS BLVD
Practice Address - Street 2:STE 203
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2495
Practice Address - Country:US
Practice Address - Phone:918-331-2525
Practice Address - Fax:918-331-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X, 3336C0004X, 333600000X
OK9-25073336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100237130AMedicaid
2073828OtherPK