Provider Demographics
NPI:1700940491
Name:CALVIN HARKINS DBA CORNER DRUG STORE
Entity Type:Organization
Organization Name:CALVIN HARKINS DBA CORNER DRUG STORE
Other - Org Name:CORNER DRUG STORE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HARKINS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-795-3376
Mailing Address - Street 1:100 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-2239
Mailing Address - Country:US
Mailing Address - Phone:580-795-3376
Mailing Address - Fax:580-795-3255
Practice Address - Street 1:100 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-2239
Practice Address - Country:US
Practice Address - Phone:580-795-3376
Practice Address - Fax:580-795-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK684095332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1172980001Medicare ID - Type UnspecifiedMEDICARE PROVIDER #