Healthcare Provider Details

I. General information

NPI: 1871227801
Provider Name (Legal Business Name): KEVIN TODD ROADY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N MAY AVE STE B
OKLAHOMA CITY OK
73112-6953
US

IV. Provider business mailing address

1202 WHISPERING RIDGE DR
TUTTLE OK
73089-8607
US

V. Phone/Fax

Practice location:
  • Phone: 405-843-6691
  • Fax: 405-848-3591
Mailing address:
  • Phone: 405-834-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number12215
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: