Organization
SHATTUCK PHARMACY MANAGEMENT INC
Active
Other names
MEDIC PHARMACY & GIFTS
Organization subpart
No
Provider details
NPI number
Authorized official
KYLE JOHNSON DPH (PIC)
(580) 938-2854
Entity
Organization
Contact information
Practice address
522 S MAIN ST, SHATTUCK, OK 73858-9604
(580) 938-2854
(580) 938-2888
Mailing address
PO BOX 99, 522 S. MAIN STREET, SHATTUCK, OK 73858-0099
(580) 938-2854
(580) 938-2888
Taxonomy
Speciality
Code
Description
License number
State
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
75-5618
OK
3336C0004X
Compounding Pharmacy
—
—
3336L0003X
Long Term Care Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100243730A
—
OK
01
—
2074859
PK
—
Enumeration date
10/26/2006
Last updated
10/27/2021
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