Provider Demographics
NPI:1538408216
Name:FAIRFAX MEDICAL FACILITIES, INC.
Entity type:Organization
Organization Name:FAIRFAX MEDICAL FACILITIES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-642-3100
Mailing Address - Street 1:212 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-3023
Mailing Address - Country:US
Mailing Address - Phone:580-362-2556
Mailing Address - Fax:580-362-3165
Practice Address - Street 1:716 S HIGHWAY 77
Practice Address - Street 2:A
Practice Address - City:NEWKIRK
Practice Address - State:OK
Practice Address - Zip Code:74647-7009
Practice Address - Country:US
Practice Address - Phone:580-362-2555
Practice Address - Fax:580-362-2948
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRFAX MEDICAL FACILITIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-31
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9399183500000X
3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200071420LMedicaid
OK6-6170OtherOKLAHOMA STATE BOARD OF PHARMACY