Provider Demographics
NPI:1124228945
Name:BOARD OF REGENTS OF THE UNIVERSITY
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY
Other - Org Name:OU CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR OF PHCY OPER
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHADID
Authorized Official - Suffix:
Authorized Official - Credentials:DPH MBA
Authorized Official - Phone:405-271-6878
Mailing Address - Street 1:4444 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2527
Mailing Address - Country:US
Mailing Address - Phone:918-619-4990
Mailing Address - Fax:918-619-4991
Practice Address - Street 1:4444 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2527
Practice Address - Country:US
Practice Address - Phone:918-619-4990
Practice Address - Fax:918-619-4991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK2-51813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200117950AMedicaid
2077133OtherPK
OK200117950AMedicaid