Provider Demographics
NPI:1902999345
Name:KEN'S HEALTHMART LLC
Entity Type:Organization
Organization Name:KEN'S HEALTHMART LLC
Other - Org Name:KENS HEALTHMART PHARMACY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HIBBARD
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:918-225-5200
Mailing Address - Street 1:200 S HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CUSHING
Mailing Address - State:OK
Mailing Address - Zip Code:74023-4117
Mailing Address - Country:US
Mailing Address - Phone:918-225-5200
Mailing Address - Fax:918-225-0828
Practice Address - Street 1:200 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4117
Practice Address - Country:US
Practice Address - Phone:918-225-5200
Practice Address - Fax:918-225-0828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK8-28343336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073600OtherPK
OK100235560AMedicaid