Healthcare Provider Details

I. General information

NPI: 1386086585
Provider Name (Legal Business Name): KELSEY LACKEY PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2013
Last Update Date: 05/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E 41ST ST SUITE 2H23
TULSA OK
74135-2536
US

IV. Provider business mailing address

10117 S FULTON AVE
TULSA OK
74137-6047
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3018
  • Fax:
Mailing address:
  • Phone: 620-330-7680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberR-15309
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: