Basic Information
| Provider Information | |||||||||
| NPI: | 1538769005 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANFORD | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2551 CLASSEN BLVD | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730714381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055157423 | ||||||||
| FaxNumber: | 4055157420 | ||||||||
| Practice Location | |||||||||
| Address1: | 2551 CLASSEN BLVD | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730714381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055157423 | ||||||||
| FaxNumber: | 4055157420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2020 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 14995 | OK | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 14995 | 01 | OK | 14995 | OTHER |