Healthcare Provider Details

I. General information

NPI: 1699333716
Provider Name (Legal Business Name): LISA STANDRIDGE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 N COUNCIL RD
BLANCHARD OK
73010-8000
US

IV. Provider business mailing address

PO BOX 786
BLANCHARD OK
73010-0786
US

V. Phone/Fax

Practice location:
  • Phone: 405-485-2112
  • Fax: 405-485-8661
Mailing address:
  • Phone: 405-485-2112
  • Fax: 405-485-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11874
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: