Basic Information
| Provider Information | |||||||||
| NPI: | 1619242260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHEDD | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMOUSE | ||||||||
| OtherFirstName: | SARA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | ONE CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677037 | ||||||||
| Practice Location | |||||||||
| Address1: | ONE CHOCTAW WAY | ||||||||
| Address2: | |||||||||
| City: | TALIHINA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185677000 | ||||||||
| FaxNumber: | 9185677037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2012 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 3921 | HI | N | Pharmacy Service Providers | Pharmacist | 1835P0018X | 14436 | OK | Y | Pharmacy Service Providers | Pharmacist | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist | 183500000X | 20954 | IA | N | Pharmacy Service Providers | Pharmacist |
No ID Information.