Provider Demographics
NPI:1134202187
Name:HEROD DRUG, LLC.
Entity type:Organization
Organization Name:HEROD DRUG, LLC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PIC/AUTH
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HARRELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-886-3445
Mailing Address - Street 1:PO BOX 603
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OK
Mailing Address - Zip Code:73724
Mailing Address - Country:US
Mailing Address - Phone:580-886-3444
Mailing Address - Fax:580-886-3445
Practice Address - Street 1:212 W MAIN
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OK
Practice Address - Zip Code:73724
Practice Address - Country:US
Practice Address - Phone:580-886-3444
Practice Address - Fax:580-886-3445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK49-60453336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100245360AMedicaid
3714967OtherNCPDP
2074042OtherPK