Healthcare Provider Details

I. General information

NPI: 1811591621
Provider Name (Legal Business Name): ELLEN ELAINE WOOD R.PH.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2020
Last Update Date: 11/23/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 E MAIN ST
HENRYETTA OK
74437-4439
US

IV. Provider business mailing address

PO BOX 288
EUFAULA OK
74432-0288
US

V. Phone/Fax

Practice location:
  • Phone: 918-652-9447
  • Fax: 918-652-8802
Mailing address:
  • Phone: 405-323-4828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number25165
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6373
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number10022
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: