Healthcare Provider Details

I. General information

NPI: 1740709252
Provider Name (Legal Business Name): FREDERICK PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2017
Last Update Date: 09/19/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 E JOSEPHINE AVE
FREDERICK OK
73542-2017
US

IV. Provider business mailing address

PO BOX 981
FREDERICK OK
73542-0981
US

V. Phone/Fax

Practice location:
  • Phone: 580-335-7575
  • Fax: 580-335-7577
Mailing address:
  • Phone: 580-335-5501
  • Fax: 580-335-7253

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number42-8026
License Number StateOK

VIII. Authorized Official

Name: SHANE KELLY
Title or Position: SECRETARY
Credential: DPH
Phone: 580-335-5501