Provider Demographics
NPI:1073359147
Name:MCKIBBIN, SCOTT
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:
Last Name:MCKIBBIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 E 96TH ST N
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-4778
Mailing Address - Country:US
Mailing Address - Phone:918-924-3625
Mailing Address - Fax:
Practice Address - Street 1:12902 E 96TH ST N
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4778
Practice Address - Country:US
Practice Address - Phone:918-272-2376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist