Healthcare Provider Details

I. General information

NPI: 1366782047
Provider Name (Legal Business Name): KEYES COMPOUNDING & SPECIALY DRUG
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W ROGER MILLER BLVD
ERICK OK
73645-0090
US

IV. Provider business mailing address

2103 S MAIN ST SUITE K
ELK CITY OK
73644-9166
US

V. Phone/Fax

Practice location:
  • Phone: 580-526-3311
  • Fax: 580-526-3275
Mailing address:
  • Phone: 580-225-5273
  • Fax: 580-303-4483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number356172
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUZANNE KEYES
Title or Position: OWNER
Credential:
Phone: 580-526-3311