Provider Demographics
NPI:1316529803
Name:GOOD SHEPHERD COMMUNITY CLINIC, INC.
Entity type:Organization
Organization Name:GOOD SHEPHERD COMMUNITY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-223-3411
Mailing Address - Street 1:20 12TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-5722
Mailing Address - Country:US
Mailing Address - Phone:580-826-3575
Mailing Address - Fax:580-223-5113
Practice Address - Street 1:1104 WALNUT DR W
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401
Practice Address - Country:US
Practice Address - Phone:580-226-0543
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOD SHEPHERD COMMUNITY CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-04-23
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK12-8917OtherPHARMACY LICENSE