Basic Information
| Provider Information | |||||||||
| NPI: | 1356943070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIMA | ||||||||
| FirstName: | MANDRIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S SOONER RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731355428 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4900 S SOONER RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731355428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054586260 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2020 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3336C0003X | 16975 | OK | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.