Healthcare Provider Details

I. General information

NPI: 1033474465
Provider Name (Legal Business Name): LARRY R LEWIS DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 07/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 N 3RD ST
LANGLEY OK
74350
US

IV. Provider business mailing address

8170 E 31ST ST
TULSA OK
74145-1717
US

V. Phone/Fax

Practice location:
  • Phone: 918-782-3271
  • Fax:
Mailing address:
  • Phone: 918-663-2560
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number8381
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: