Provider Demographics
NPI:1508945486
Name:GUYMON CLINIC PHARMACY LLC
Entity Type:Organization
Organization Name:GUYMON CLINIC PHARMACY LLC
Other - Org Name:CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-338-3339
Mailing Address - Street 1:PO BOX 1590
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-1590
Mailing Address - Country:US
Mailing Address - Phone:580-338-3339
Mailing Address - Fax:580-338-1010
Practice Address - Street 1:1210 N LELIA ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3647
Practice Address - Country:US
Practice Address - Phone:580-338-3339
Practice Address - Fax:580-338-1010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
OK4350143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2081576OtherPK
OK100241140AMedicaid