Shattuck Pharmacy Management Inc
Organization Active NPI Community/Retail Pharmacy · Shattuck, OK
NPI 1720163959 · NPPES record last updated Jul 6, 2026
Key facts
- NPI
- 1720163959
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community/Retail Pharmacy 3336C0003X
- License
- 75-5618 (OK)
- Legal business name
- SHATTUCK PHARMACY MANAGEMENT INC
- Practice address
- 1604 S Main St
Shattuck, OK 73858-9226 - Phone
- (580) 938-2854
- Fax
- (580) 938-2888
- NPI assigned
- Oct 26, 2006
- Organization subpart
- No
Authorized official
- Name
- Kyle Johnson, DPH
- Title
- Pic
- Phone
- (580) 938-2854
Practitioners 4
-
Kyle B Johnson, D.PH.
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 37D2188431 | Medic Pharmacy & Gifts | Certificate of waiver | Jul 15, 2028 |
Medicare medical equipment & supply locations
| Supplier | Supplies | Medicare assignment |
|---|---|---|
| Medic Pharmacy & Gifts |
Nebulizer Drugs|Commodes, Urinals, Bedpans|Blood Glucose Monitors/Supplies (Non-Mail Order)|Canes and/or Crutches|Walkers|Wheelchairs (Standard Manual)|Wheelchairs (Standard Manual Related Accessories)|Wheelchair Seating/Cushions|Ostomy Supplies|Urological Supplies|Nebulizer Equipment and/or Suppli… | Accepts assignment |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in OK
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20091006000041 | OK | Part B Supplier - Mass Immunization (Roster Biller Only) | 6305982307 | Practice locations: Shattuck, OK |
| O20100930027732 | OK | DME Supplier - Pharmacy | 6305982307 | Practice locations: Shattuck, OK |
National Provider Directory
Locations
522 S Main St
Shattuck, OK 73858
Phone (580) 938-2854
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | |||
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | 75-5618 | OK | Yes |
| Compounding Pharmacy | 3336C0004X | |||
| Long Term Care Pharmacy | 3336L0003X |
Addresses
Primary practice location
1604 S Main St
Shattuck, OK 73858-9226
Mailing address
1604 S Main St
PO Box 99
Shattuck, OK 73858-9226
Phone (580) 938-2854
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100243730A | Medicaid | OK | |
| 2074859 | Other | PK |
Other names
- MEDIC PHARMACY & GIFTS
Other providers in Shattuck, OK
- Lisa Marie Oakley
- Jerson Penaflor
- Scott Eye Care P L L C
- Shattuck Dentistry & Braces
- Shattuck Nursing Center Inc
- Shattuck Public Schools
- Stuart Family Medicine, PLLC
- Stuart Family Medicine, PLLC.
- Danna K Stuart
All providers in Shattuck, OK · Community/Retail Pharmacy in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jul 6, 2026. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.