Provider Demographics
NPI:1104145846
Name:BMTTH LLC
Entity type:Organization
Organization Name:BMTTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-761-7932
Mailing Address - Street 1:2432 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-4807
Mailing Address - Country:US
Mailing Address - Phone:580-920-1400
Mailing Address - Fax:580-920-1451
Practice Address - Street 1:2432 W MAIN ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-4807
Practice Address - Country:US
Practice Address - Phone:580-920-1400
Practice Address - Fax:580-920-1451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27-72013336C0003X
OK2755343336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200292460AMedicaid
2125165OtherPK
0233892000Medicare PIN