Healthcare Provider Details

I. General information

NPI: 1700376431
Provider Name (Legal Business Name): OLIVER DE LOS ANGELES PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 05/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 NE 13TH ST
OKLAHOMA CITY OK
73104-5007
US

IV. Provider business mailing address

2300 NW 191ST CT
EDMOND OK
73012-2640
US

V. Phone/Fax

Practice location:
  • Phone: 405-456-1000
  • Fax:
Mailing address:
  • Phone: 913-484-7467
  • Fax: 913-484-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208U00000X
TaxonomyClinical Pharmacology Physician
License Number17267
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: