Provider Demographics
NPI:1114087350
Name:CHICKASHA CLINIC PHARMACY LLC
Entity Type:Organization
Organization Name:CHICKASHA CLINIC PHARMACY LLC
Other - Org Name:CHICKASHA CLINIC PHARMACY, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-447-3911
Mailing Address - Street 1:2224 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASHA
Mailing Address - State:OK
Mailing Address - Zip Code:73018-2738
Mailing Address - Country:US
Mailing Address - Phone:405-224-4851
Mailing Address - Fax:405-222-9157
Practice Address - Street 1:2224 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:CHICKASHA
Practice Address - State:OK
Practice Address - Zip Code:73018-2738
Practice Address - Country:US
Practice Address - Phone:405-224-4851
Practice Address - Fax:405-222-9157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OK18-59293336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100236490AMedicaid
2135238OtherPK
6723960001Medicare NSC