Healthcare Provider Details

I. General information

NPI: 1699867549
Provider Name (Legal Business Name): SHAMROCK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W CHOCTAW ST
TAHLEQUAH OK
74464-3369
US

IV. Provider business mailing address

200 W CHOCTAW ST
TAHLEQUAH OK
74464-3808
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-4797
  • Fax: 918-456-8413
Mailing address:
  • Phone: 918-456-4797
  • Fax: 918-456-8413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier100809610A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: RANDY M TAYLOR
Title or Position: CEO/PRESIDENT
Credential:
Phone: 918-456-4797