Provider Demographics
NPI:1053796235
Name:CLINIC PHARMACY OF CORDELL INC
Entity type:Organization
Organization Name:CLINIC PHARMACY OF CORDELL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-832-3714
Mailing Address - Street 1:1213 N GLENN ENGLISH ST
Mailing Address - Street 2:
Mailing Address - City:CORDELL
Mailing Address - State:OK
Mailing Address - Zip Code:73632-2009
Mailing Address - Country:US
Mailing Address - Phone:580-832-3714
Mailing Address - Fax:580-832-3331
Practice Address - Street 1:1213 N GLENN ENGLISH ST
Practice Address - Street 2:
Practice Address - City:CORDELL
Practice Address - State:OK
Practice Address - Zip Code:73632-2009
Practice Address - Country:US
Practice Address - Phone:580-832-3714
Practice Address - Fax:580-832-3331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-29
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X, 3336L0003X
OK33-74143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2154068OtherPK
OK200608360AMedicaid