Healthcare Provider Details

I. General information

NPI: 1467906412
Provider Name (Legal Business Name): KYLE T PANTER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2016
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 N ELM PL
BROKEN ARROW OK
74012-2539
US

IV. Provider business mailing address

1704 S MAPLE AVE
BROKEN ARROW OK
74012-6671
US

V. Phone/Fax

Practice location:
  • Phone: 918-449-9988
  • Fax: 918-449-9989
Mailing address:
  • Phone: 918-258-1522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number12685
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: