MEDICARE: LEA WILLIAMSON BLACK PHARMACIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	11827	OK

General Provider Information

NPI Number	:	1669072047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEA WILLIAMSON BLACK PHARMACIST

Provider Business Mailing Address
First Line	:	3408 STATE HIGHWAY 37
Second Line	:
City	:	GARVIN
State	:	OK
Zip	:	74736-5314
Country	:	US
Telephone Number	:	580-212-8678
Fax Number	:

Provider Business Practice Location Address
First Line	:	1907 SE WASHINGTON ST
Second Line	:
City	:	IDABEL
State	:	OK
Zip	:	74745-5253
Country	:	US
Telephone Number	:	580-286-3323
Fax Number	:	580-286-2396

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	10/27/2020

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