Provider Demographics
NPI:1851308324
Name:SHAWNEE REGIONAL PHARMACY INC
Entity Type:Organization
Organization Name:SHAWNEE REGIONAL PHARMACY INC
Other - Org Name:MCLOUD CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RX MANAGER/CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:405-964-3956
Mailing Address - Street 1:704 S 8TH ST
Mailing Address - Street 2:STE B
Mailing Address - City:MCLOUD
Mailing Address - State:OK
Mailing Address - Zip Code:74851-8633
Mailing Address - Country:US
Mailing Address - Phone:405-964-3956
Mailing Address - Fax:405-964-3959
Practice Address - Street 1:704 S 8TH ST
Practice Address - Street 2:STE B
Practice Address - City:MCLOUD
Practice Address - State:OK
Practice Address - Zip Code:74851-8633
Practice Address - Country:US
Practice Address - Phone:405-964-3956
Practice Address - Fax:405-964-3959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10-48993336C0003X, 3336C0003X, 3336C0003X
3336C0004X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100233850BMedicaid
2076963OtherPK
0258100003Medicare PIN