Healthcare Provider Details

I. General information

NPI: 1942458930
Provider Name (Legal Business Name): JOHN COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 09/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S MOORE AVE
CLAREMORE OK
74017-5047
US

IV. Provider business mailing address

2506 TRAILWOOD DR
CLAREMORE OK
74017-4833
US

V. Phone/Fax

Practice location:
  • Phone: 918-342-6489
  • Fax:
Mailing address:
  • Phone: 918-342-6489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14318
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: