Healthcare Provider Details

I. General information

NPI: 1548268055
Provider Name (Legal Business Name): BOB N DISHMAN R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 SW LEE BLVD
LAWTON OK
73501-5610
US

IV. Provider business mailing address

1310 SW LEE BLVD
LAWTON OK
73501-5610
US

V. Phone/Fax

Practice location:
  • Phone: 580-353-8560
  • Fax: 580-353-7985
Mailing address:
  • Phone: 580-353-8560
  • Fax: 580-353-7985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number6685
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: