Provider Demographics
NPI:1295000685
Name:OKLAHOMA CANCER SPECIALISTS AND RESEARCH INSTITUTE LLC
Entity type:Organization
Organization Name:OKLAHOMA CANCER SPECIALISTS AND RESEARCH INSTITUTE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLYARD
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:918-505-3202
Mailing Address - Street 1:12697 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-6236
Mailing Address - Country:US
Mailing Address - Phone:918-505-3252
Mailing Address - Fax:918-505-3251
Practice Address - Street 1:12697 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6236
Practice Address - Country:US
Practice Address - Phone:918-505-3252
Practice Address - Fax:918-505-3251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27544333600000X
3336S0011X
KS22-1006593336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134209OtherPK
OK2006270908AMedicaid
467378Medicare PIN