=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962895631
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STANBRO HEALTHCARE GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2015
-----------------------------------------------------
Last Update Date | 04/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 E 15TH ST SUITE 400C
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-6697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-562-6434
-----------------------------------------------------
Fax | 405-285-6121
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1620 W NORTHWEST HWY STE. 100
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-3177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-572-0009
-----------------------------------------------------
Fax | 817-720-1039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR., LICENSING & THIRD PARTY
-----------------------------------------------------
Name | TAMMIE MISKIMINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-572-0009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number | 17167
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------