Healthcare Provider Details

I. General information

NPI: 1508728361
Provider Name (Legal Business Name): TREVOR HORNBERGER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2025
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10914 E 61ST ST APT 328
TULSA OK
74133-1564
US

IV. Provider business mailing address

10914 E 61ST ST APT 328
TULSA OK
74133-1564
US

V. Phone/Fax

Practice location:
  • Phone: 580-470-6239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number21040
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: