Provider Demographics
NPI:1821547134
Name:NEW SPRING PHARMACY, LLC
Entity Type:Organization
Organization Name:NEW SPRING PHARMACY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-938-0440
Mailing Address - Street 1:3462 W 151ST ST S
Mailing Address - Street 2:
Mailing Address - City:KIEFER
Mailing Address - State:OK
Mailing Address - Zip Code:74041-4549
Mailing Address - Country:US
Mailing Address - Phone:918-938-0440
Mailing Address - Fax:918-938-0453
Practice Address - Street 1:3462 W 151ST ST S
Practice Address - Street 2:
Practice Address - City:KIEFER
Practice Address - State:OK
Practice Address - Zip Code:74041-4549
Practice Address - Country:US
Practice Address - Phone:918-938-0440
Practice Address - Fax:918-938-0543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2-77513336C0003X, 3336C0004X, 3336C0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200671740AMedicaid