Provider Demographics
NPI:1023102431
Name:KENDALL HEALTHMART INC.
Entity type:Organization
Organization Name:KENDALL HEALTHMART INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-396-2411
Mailing Address - Street 1:222 E ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-1250
Mailing Address - Country:US
Mailing Address - Phone:918-396-2411
Mailing Address - Fax:918-396-4067
Practice Address - Street 1:222 E ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-1250
Practice Address - Country:US
Practice Address - Phone:918-396-2411
Practice Address - Fax:918-396-4067
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK225253336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2081523OtherPK
OK100238010AMedicaid