Healthcare Provider Details

I. General information

NPI: 1912063892
Provider Name (Legal Business Name): GRINNELL PRESCRIPTION SHOP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 01/07/2022
Certification Date: 01/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S BROADWAY
HOBART OK
73651-1862
US

IV. Provider business mailing address

PO BOX 192
HOBART OK
73651-0192
US

V. Phone/Fax

Practice location:
  • Phone: 580-726-5613
  • Fax: 580-726-3511
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number413479
License Number StateOK

VIII. Authorized Official

Name: STEVE MILLER
Title or Position: OWNER
Credential: DPH
Phone: 580-726-5613