Provider Demographics
NPI:1598853137
Name:SHACKELFORD, CHARLIE (BS PHARM)
Entity Type:Individual
Prefix:MR
First Name:CHARLIE
Middle Name:
Last Name:SHACKELFORD
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14104 E 87TH TER N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2580
Mailing Address - Country:US
Mailing Address - Phone:918-274-6355
Mailing Address - Fax:
Practice Address - Street 1:1020 LENAPE DR
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-4403
Practice Address - Country:US
Practice Address - Phone:918-273-7552
Practice Address - Fax:918-273-3234
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12586OtherSTATE LICENCE NUMBER