Provider Demographics
NPI:1386074946
Name:NW BARTLESVILLE LLC
Entity type:Organization
Organization Name:NW BARTLESVILLE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PERKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-258-4399
Mailing Address - Street 1:PO BOX 34407
Mailing Address - Street 2:PMB 53760
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-4407
Mailing Address - Country:US
Mailing Address - Phone:501-534-4459
Mailing Address - Fax:501-534-4460
Practice Address - Street 1:143 SE WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2334
Practice Address - Country:US
Practice Address - Phone:918-876-4204
Practice Address - Fax:918-876-4206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9-6509333600000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2144292OtherPK
OK200532030AMedicaid