Healthcare Provider Details

I. General information

NPI: 1215958285
Provider Name (Legal Business Name): EASTSIDE CLINIC PHARMACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2006
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3612 SE LEE BLVD
LAWTON OK
73501-8451
US

IV. Provider business mailing address

3612 SE LEE BLVD
LAWTON OK
73501-8451
US

V. Phone/Fax

Practice location:
  • Phone: 580-355-6400
  • Fax: 580-355-0451
Mailing address:
  • Phone: 580-355-6400
  • Fax: 580-355-0451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number36455
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: J BRENNAN
Title or Position: PARTNER PHARMACIST IN CHARGE
Credential:
Phone: 580-355-6400