Healthcare Provider Details

I. General information

NPI: 1750392114
Provider Name (Legal Business Name): DAVID RAY MCMILLIN D.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

312 W 12TH ST
ADA OK
74820-6406
US

IV. Provider business mailing address

1513 AUGUSTA DR
ADA OK
74820-8576
US

V. Phone/Fax

Practice location:
  • Phone: 580-332-8888
  • Fax: 580-332-7965
Mailing address:
  • Phone: 580-332-0983
  • Fax: 580-332-7965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11769
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11769
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerPHARMACIST LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: