=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386321024
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAUREN JAE CHASTAIN PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2023
-----------------------------------------------------
Last Update Date | 07/04/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 S MOORE AVE
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74017-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-342-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 84127 HIGHWAY 59
-----------------------------------------------------
City | STILWELL
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74960-4257
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-696-3186
-----------------------------------------------------
Fax | 918-696-3285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 20056
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------