Provider Demographics
NPI:1548887771
Name:BROKEN OAK LLC
Entity type:Organization
Organization Name:BROKEN OAK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:509-740-0833
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:OKANOGAN
Mailing Address - State:WA
Mailing Address - Zip Code:98840-0265
Mailing Address - Country:US
Mailing Address - Phone:509-846-4910
Mailing Address - Fax:
Practice Address - Street 1:208 S MAIN ST
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9755
Practice Address - Country:US
Practice Address - Phone:509-740-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-03
Last Update Date:2020-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
No183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Single Specialty
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0002XSuppliersPharmacyClinic Pharmacy