Provider Demographics
NPI:1821185448
Name:PHYSICIANS & SURGEONS PHARMACY INC
Entity Type:Organization
Organization Name:PHYSICIANS & SURGEONS PHARMACY INC
Other - Org Name:PHYSICIANS AND SURGEONS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLINTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS PHARMACY
Authorized Official - Phone:405-307-2155
Mailing Address - Street 1:900 N PORTER AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6425
Mailing Address - Country:US
Mailing Address - Phone:405-364-5222
Mailing Address - Fax:405-364-7076
Practice Address - Street 1:900 N PORTER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6425
Practice Address - Country:US
Practice Address - Phone:405-364-5222
Practice Address - Fax:405-364-7076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 3336C0004X
OK717713336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074141OtherPK
OK100234860BMedicaid
OK100234860AMedicaid
2074141OtherPK