Healthcare Provider Details

I. General information

NPI: 1558358150
Provider Name (Legal Business Name): RYAN STEVENS DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1/2 MILE WEST HIGHWAY 9
CARNEGIE OK
73015
US

IV. Provider business mailing address

RR 1 BOX 288
GRACEMONT OK
73042-9612
US

V. Phone/Fax

Practice location:
  • Phone: 580-654-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12788
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: