Provider Demographics
NPI:1366782047
Name:KEYES COMPOUNDING & SPECIALY DRUG
Entity type:Organization
Organization Name:KEYES COMPOUNDING & SPECIALY DRUG
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:KEYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-526-3311
Mailing Address - Street 1:2103 S MAIN ST
Mailing Address - Street 2:SUITE K
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-9166
Mailing Address - Country:US
Mailing Address - Phone:580-225-5273
Mailing Address - Fax:580-303-4483
Practice Address - Street 1:215 W ROGER MILLER BLVD
Practice Address - Street 2:
Practice Address - City:ERICK
Practice Address - State:OK
Practice Address - Zip Code:73645-0090
Practice Address - Country:US
Practice Address - Phone:580-526-3311
Practice Address - Fax:580-526-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-18
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
OK3561723336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2139255OtherPK