Healthcare Provider Details

I. General information

NPI: 1053924969
Provider Name (Legal Business Name): KEENUM PHARMACY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N MAIN ST
ALTUS OK
73521-1605
US

IV. Provider business mailing address

2101 N MAIN ST
ALTUS OK
73521-1605
US

V. Phone/Fax

Practice location:
  • Phone: 580-477-0381
  • Fax: 580-477-1749
Mailing address:
  • Phone: 580-477-0381
  • Fax: 580-477-1749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KYLE KEENUM
Title or Position: PHARMACY MANAGER
Credential:
Phone: 580-477-0381