Provider Demographics
NPI:1700344587
Name:ADAMS, LARRY SHANE (DPH)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:SHANE
Last Name:ADAMS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-4408
Mailing Address - Country:US
Mailing Address - Phone:405-375-5400
Mailing Address - Fax:405-375-6333
Practice Address - Street 1:1308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-4408
Practice Address - Country:US
Practice Address - Phone:405-375-5400
Practice Address - Fax:405-375-6333
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-11
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK115571835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK11557OtherPHARMACY LICENSE