MEDICARE: OKLAHOMA STATE UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	261QS1000X	Student Health Clinic/Center	8-3015	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	736017987	OTHER	OK	FEDERAL TAX ID
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598827776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKLAHOMA STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	1202 W FARM RD
Second Line	:
City	:	STILLWATER
State	:	OK
Zip	:	74078-2036
Country	:	US
Telephone Number	:	405-744-7025
Fax Number	:	405-744-2136

Provider Business Practice Location Address
First Line	:	1202 W FARM RD
Second Line	:
City	:	STILLWATER
State	:	OK
Zip	:	74078-2036
Country	:	US
Telephone Number	:	405-744-7665
Fax Number	:	405-744-2136

Authorized Official
Title or Position	:	ASSOCIATE DIRECTOR
Name	:	MR. JACK HENNEHA
Credential	:
Telephone Number	:	405-744-7665

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	01/25/2022

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Directions to “OKLAHOMA STATE UNIVERSITY ” Practice Location

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