Provider Demographics
NPI:1124427745
Name:BETHEL PHARMACY LLC
Entity type:Organization
Organization Name:BETHEL PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:KANWHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-505-9650
Mailing Address - Street 1:205 E PINE ST STE 7
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-4859
Mailing Address - Country:US
Mailing Address - Phone:918-505-9650
Mailing Address - Fax:918-518-7182
Practice Address - Street 1:205 E PINE ST STE 7
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-4859
Practice Address - Country:US
Practice Address - Phone:918-505-9650
Practice Address - Fax:918-518-7182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK2-68143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200570490AMedicaid
2147863OtherPK
390511Medicare PIN