Healthcare Provider Details

I. General information

NPI: 1366535114
Provider Name (Legal Business Name): STEPHEN WADE FORD D.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19655 NE 23RD ST
HARRAH OK
73045-9305
US

IV. Provider business mailing address

PO BOX 12386
OKLAHOMA CITY OK
73157-2386
US

V. Phone/Fax

Practice location:
  • Phone: 405-454-6261
  • Fax: 405-454-6262
Mailing address:
  • Phone: 405-454-6261
  • Fax: 405-454-6262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10554
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: