1053924969 NPI number — KEENUM PHARMACY, LLC

Table of content: (NPI 1053924969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053924969 NPI number — KEENUM PHARMACY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEENUM PHARMACY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053924969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/11/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2101 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALTUS
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73521-1605
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-477-0381
Provider Business Mailing Address Fax Number:
580-477-1749

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2101 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALTUS
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73521-1605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-477-0381
Provider Business Practice Location Address Fax Number:
580-477-1749
Provider Enumeration Date:
08/28/2020

Additional Information

Authorized Official

Authorized Official Last Name:
KEENUM
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
580-477-0381

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200956270A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com