Provider Demographics
NPI:1720163959
Name:SHATTUCK PHARMACY MANAGEMENT INC
Entity Type:Organization
Organization Name:SHATTUCK PHARMACY MANAGEMENT INC
Other - Org Name:MEDIC PHARMACY & GIFTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-938-2854
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:522 S. MAIN STREET
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-0099
Mailing Address - Country:US
Mailing Address - Phone:580-938-2854
Mailing Address - Fax:580-938-2888
Practice Address - Street 1:522 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858-9604
Practice Address - Country:US
Practice Address - Phone:580-938-2854
Practice Address - Fax:580-938-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
OK75-56183336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100243730AMedicaid
2074859OtherPK
1039240001Medicare PIN