Healthcare Provider Details

I. General information

NPI: 1801112784
Provider Name (Legal Business Name): SONG Y LAVALAIS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2010
Last Update Date: 04/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 E LINCOLN RD
IDABEL OK
74745-7337
US

IV. Provider business mailing address

902 E LINCOLN RD
IDABEL OK
74745-7337
US

V. Phone/Fax

Practice location:
  • Phone: 580-286-2600
  • Fax: 580-286-4714
Mailing address:
  • Phone: 580-286-2600
  • Fax: 580-286-4714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number14364
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: