Provider Demographics
NPI:1164578902
Name:CLAYTON PHARMACY
Entity Type:Organization
Organization Name:CLAYTON PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PIC
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:YANCHICK
Authorized Official - Suffix:
Authorized Official - Credentials:MPH DPH
Authorized Official - Phone:918-569-4884
Mailing Address - Street 1:102 LAWSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:OK
Mailing Address - Zip Code:74536-0517
Mailing Address - Country:US
Mailing Address - Phone:918-569-4884
Mailing Address - Fax:918-569-4660
Practice Address - Street 1:102 LAWSON BLVD
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:OK
Practice Address - Zip Code:74536-0517
Practice Address - Country:US
Practice Address - Phone:918-569-4884
Practice Address - Fax:918-569-4660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK534300332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100244280BMedicaid
OK100244280BMedicaid