Provider Demographics
NPI:1053924969
Name:KEENUM PHARMACY, LLC
Entity type:Organization
Organization Name:KEENUM PHARMACY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEENUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-477-0381
Mailing Address - Street 1:2101 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-1605
Mailing Address - Country:US
Mailing Address - Phone:580-477-0381
Mailing Address - Fax:580-477-1749
Practice Address - Street 1:2101 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-1605
Practice Address - Country:US
Practice Address - Phone:580-477-0381
Practice Address - Fax:580-477-1749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-28
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200956270AMedicaid