Provider Demographics
NPI:1720171168
Name:PHARMOLOGY BRISTOW LLC
Entity Type:Organization
Organization Name:PHARMOLOGY BRISTOW LLC
Other - Org Name:SUPER H PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-261-3048
Mailing Address - Street 1:201 E 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-2503
Mailing Address - Country:US
Mailing Address - Phone:918-367-3328
Mailing Address - Fax:918-367-2415
Practice Address - Street 1:201 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-2503
Practice Address - Country:US
Practice Address - Phone:918-367-3328
Practice Address - Fax:918-367-2415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11-53743336C0003X, 3336C0003X
3336C0004X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100236210AMedicaid
2073744OtherPK
OK100236210AMedicaid
OK100808080AMedicaid