Provider Demographics
NPI:1740709252
Name:FREDERICK PHARMACY INC
Entity type:Organization
Organization Name:FREDERICK PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-335-5501
Mailing Address - Street 1:PO BOX 981
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73542-0981
Mailing Address - Country:US
Mailing Address - Phone:580-335-5501
Mailing Address - Fax:580-335-7253
Practice Address - Street 1:219 E JOSEPHINE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:OK
Practice Address - Zip Code:73542-2017
Practice Address - Country:US
Practice Address - Phone:580-335-7575
Practice Address - Fax:580-335-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-15
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK42-80263336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200008420AMedicaid