Healthcare Provider Details

I. General information

NPI: 1598827776
Provider Name (Legal Business Name): OKLAHOMA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 W FARM RD
STILLWATER OK
74078-2036
US

IV. Provider business mailing address

1202 W FARM RD
STILLWATER OK
74078-2036
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-7665
  • Fax: 405-744-2136
Mailing address:
  • Phone: 405-744-7025
  • Fax: 405-744-2136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number8-3015
License Number StateOK

VIII. Authorized Official

Name: MR. JACK HENNEHA
Title or Position: ASSOCIATE DIRECTOR
Credential:
Phone: 405-744-7665