Healthcare Provider Details

I. General information

NPI: 1053417600
Provider Name (Legal Business Name): GERALD RAY BROWN JR. PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

PO BOX 936
FORT GIBSON OK
74434-0936
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3207
  • Fax:
Mailing address:
  • Phone: 918-478-3141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number13123
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: