Healthcare Provider Details

I. General information

NPI: 1962895631
Provider Name (Legal Business Name): STANBRO HEALTHCARE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2015
Last Update Date: 04/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 E 15TH ST SUITE 400C
EDMOND OK
73013-6697
US

IV. Provider business mailing address

1620 W NORTHWEST HWY STE. 100
GRAPEVINE TX
76051-3177
US

V. Phone/Fax

Practice location:
  • Phone: 405-562-6434
  • Fax: 405-285-6121
Mailing address:
  • Phone: 817-572-0009
  • Fax: 817-720-1039

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 Number17167
License Number StateOK

VIII. Authorized Official

Name: TAMMIE MISKIMINS
Title or Position: MGR., LICENSING & THIRD PARTY
Credential:
Phone: 817-572-0009