Healthcare Provider Details

I. General information

NPI: 1245703321
Provider Name (Legal Business Name): RANDALL STUCKEY DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2019
Last Update Date: 01/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 W HWY 152
MUSTANG OK
73064
US

IV. Provider business mailing address

1404 CONTINENTAL WAY
MUSTANG OK
73064-2074
US

V. Phone/Fax

Practice location:
  • Phone: 405-376-3340
  • Fax: 405-376-1390
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12048
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: