=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952475345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIKES PHARMACY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2006
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 E 2ND STREET
-----------------------------------------------------
City | GRANDFIELD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-479-5696
-----------------------------------------------------
Fax | 580-479-5662
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 159
-----------------------------------------------------
City | GRANDFIELD
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73546-0159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-479-5696
-----------------------------------------------------
Fax | 580-479-5662
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER AND MANAGER
-----------------------------------------------------
Name | CORY FIKES
-----------------------------------------------------
Credential | DPH
-----------------------------------------------------
Telephone | 580-479-5696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 23981
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 3336C0004X
-----------------------------------------------------
Taxonomy Name | Compounding Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 3336L0003X
-----------------------------------------------------
Taxonomy Name | Long Term Care Pharmacy
-----------------------------------------------------
License Number | 424672
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------