Provider Demographics
NPI:1164594958
Name:PHARM SHAWNEE ACQUISITION LLC
Entity Type:Organization
Organization Name:PHARM SHAWNEE ACQUISITION LLC
Other - Org Name:THE MEDICINE SHOPPE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-261-3048
Mailing Address - Street 1:1006 N HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-6419
Mailing Address - Country:US
Mailing Address - Phone:405-273-7360
Mailing Address - Fax:405-273-4384
Practice Address - Street 1:1006 N HARRISON AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6419
Practice Address - Country:US
Practice Address - Phone:405-273-7360
Practice Address - Fax:405-273-4384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK10-66493336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100239580AMedicaid
2145108OtherPK
OK100239580AMedicaid
OKBM0281294OtherDEA #
OK0260070001Medicare NSC
OK100239580BMedicaid