Provider Demographics
NPI:1962895631
Name:STANBRO HEALTHCARE GROUP LLC
Entity type:Organization
Organization Name:STANBRO HEALTHCARE GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGR., LICENSING & THIRD PARTY
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MISKIMINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-572-0009
Mailing Address - Street 1:1620 W NORTHWEST HWY
Mailing Address - Street 2:STE. 100
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-3177
Mailing Address - Country:US
Mailing Address - Phone:817-572-0009
Mailing Address - Fax:817-720-1039
Practice Address - Street 1:2000 E 15TH ST
Practice Address - Street 2:SUITE 400C
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-6697
Practice Address - Country:US
Practice Address - Phone:405-562-6434
Practice Address - Fax:405-285-6121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-05
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK171673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2150608OtherPK