Provider Demographics
NPI:1932679099
Name:ZRC PHARMACY, LLC
Entity Type:Organization
Organization Name:ZRC PHARMACY, LLC
Other - Org Name:CLYDE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLYDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-517-6104
Mailing Address - Street 1:7158 NW 112TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2773
Mailing Address - Country:US
Mailing Address - Phone:405-517-6104
Mailing Address - Fax:
Practice Address - Street 1:7158 NW 112TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-2773
Practice Address - Country:US
Practice Address - Phone:405-470-7008
Practice Address - Fax:405-470-1040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200809230AMedicaid
OK1-8329OtherPHARMACY LICENSE