Provider Demographics
NPI:1952946022
Name:THE CHILDREN'S CENTER, INC. DBA BETHANY COMMUNITY PHARMACY
Entity Type:Organization
Organization Name:THE CHILDREN'S CENTER, INC. DBA BETHANY COMMUNITY PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICKETTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-470-2326
Mailing Address - Street 1:6770 NW 39TH EXPY
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:OK
Mailing Address - Zip Code:73008-2646
Mailing Address - Country:US
Mailing Address - Phone:405-440-6797
Mailing Address - Fax:405-440-6798
Practice Address - Street 1:6770 NW 39TH EXPY
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:OK
Practice Address - Zip Code:73008-2646
Practice Address - Country:US
Practice Address - Phone:405-440-6797
Practice Address - Fax:405-440-6798
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100677110JMedicaid