Provider Demographics
NPI:1912063892
Name:GRINNELL PRESCRIPTION SHOP INC
Entity Type:Organization
Organization Name:GRINNELL PRESCRIPTION SHOP INC
Other - Org Name:GRINNELL PRESCRIPTION SHOP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-726-5613
Mailing Address - Street 1:PO BOX 192
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651-0192
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:304 S BROADWAY
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-1862
Practice Address - Country:US
Practice Address - Phone:580-726-5613
Practice Address - Fax:580-726-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336L0003X
OK4134793336C0003X, 3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100236820BMedicaid
OK100236820AMedicaid
2072808OtherPK
0636760001Medicare NSC