Provider Demographics
NPI:1497837298
Name:STAR PHARMACY INC
Entity Type:Organization
Organization Name:STAR PHARMACY INC
Other - Org Name:STAR MEDICAL CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER-PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:BOBROVICZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:580-255-7165
Mailing Address - Street 1:2120 W ELK AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1537
Mailing Address - Country:US
Mailing Address - Phone:580-255-7165
Mailing Address - Fax:580-255-0720
Practice Address - Street 1:2120 W ELK AVE RM 10
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1576
Practice Address - Country:US
Practice Address - Phone:580-255-7165
Practice Address - Fax:580-255-0720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1361643336C0003X, 3336L0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100242650AMedicaid
2073447OtherPK
2073447OtherPK