Provider Demographics
NPI:1639489529
Name:TBCPM LLC
Entity Type:Organization
Organization Name:TBCPM LLC
Other - Org Name:THE BROADWAY CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-429-5138
Mailing Address - Street 1:1801 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-3446
Mailing Address - Country:US
Mailing Address - Phone:405-429-5138
Mailing Address - Fax:405-521-8260
Practice Address - Street 1:1801 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3446
Practice Address - Country:US
Practice Address - Phone:405-429-5138
Practice Address - Fax:405-521-8260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-14
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK1-55353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2126994OtherPK