Provider Demographics
NPI:1871609818
Name:NEWBERRY EXPRESS PHARMACY, LLC
Entity type:Organization
Organization Name:NEWBERRY EXPRESS PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-889-3353
Mailing Address - Street 1:744 S MISSISSIPPI AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3356
Mailing Address - Country:US
Mailing Address - Phone:580-889-0230
Mailing Address - Fax:580-889-3060
Practice Address - Street 1:801 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MARLOW
Practice Address - State:OK
Practice Address - Zip Code:73055-3433
Practice Address - Country:US
Practice Address - Phone:580-658-3784
Practice Address - Fax:580-658-3725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0003X, 3336C0004X, 3336L0003X
OK13-41703336H0001X, 3336L0003X, 3336M0002X, 3336S0011X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073880OtherPK
OK100244800AMedicaid
OK100244800BMedicaid
2073880OtherPK
2073880OtherPK
OK100244800AMedicaid
OK100244800AMedicaid
OK300522198Medicare ID - Type UnspecifiedPART B
OK=========-004OtherTRICARE PRIME
1173080001Medicare NSC