Provider Demographics
NPI:1174029748
Name:RENES, JOHN SCOTT (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SCOTT
Last Name:RENES
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 WHISPERING PINE BLVD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2409
Mailing Address - Country:US
Mailing Address - Phone:580-320-7115
Mailing Address - Fax:
Practice Address - Street 1:1900 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-8603
Practice Address - Country:US
Practice Address - Phone:405-395-5806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8638183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8638OtherOKLAHOMA STATE PHARMACY LICENSE NUMBER