Healthcare Provider Details

I. General information

NPI: 1053796235
Provider Name (Legal Business Name): CLINIC PHARMACY OF CORDELL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2015
Last Update Date: 02/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 N GLENN ENGLISH ST
CORDELL OK
73632-2009
US

IV. Provider business mailing address

1213 N GLENN ENGLISH ST
CORDELL OK
73632-2009
US

V. Phone/Fax

Practice location:
  • Phone: 580-832-3714
  • Fax: 580-832-3331
Mailing address:
  • Phone: 580-832-3714
  • Fax: 580-832-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number33-7414
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: CHRIS JOHNSON
Title or Position: PHARMACY MANAGER
Credential:
Phone: 580-832-3714