Provider Demographics
NPI:1598827776
Name:OKLAHOMA STATE UNIVERSITY
Entity Type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY
Other - Org Name:OSU UNIVERSITY HEALTH SERVICES PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:HENNEHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-744-7665
Mailing Address - Street 1:1202 W FARM RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74078-2036
Mailing Address - Country:US
Mailing Address - Phone:405-744-7025
Mailing Address - Fax:405-744-2136
Practice Address - Street 1:1202 W FARM RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74078-2036
Practice Address - Country:US
Practice Address - Phone:405-744-7665
Practice Address - Fax:405-744-2136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSU UNVIVERSITY HEALTH SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-14
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8-3015261QS1000X
333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK736017987OtherFEDERAL TAX ID
OK100757330FMedicaid