Provider Demographics
NPI:1730539487
Name:GOOD SHEPHERD COMMUNITY CLINIC, INC
Entity type:Organization
Organization Name:GOOD SHEPHERD COMMUNITY CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
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:580-223-3411
Mailing Address - Fax:
Practice Address - Street 1:20 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5722
Practice Address - Country:US
Practice Address - Phone:580-223-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3729514OtherNCPDP
OK12-8483OtherOKLAHOMA STATE BOARD OF PHARMACY LICENSE
OK12-8483OtherOKLAHOMA STATE BOARD OF PHARMACY LICENSE