Healthcare Provider Details

I. General information

NPI: 1205578002
Provider Name (Legal Business Name): MARY ANDERSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KATE ANDERSON

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 S YALE AVE
TULSA OK
74136-1902
US

IV. Provider business mailing address

9415 E 65TH ST APT 2905
TULSA OK
74133-1594
US

V. Phone/Fax

Practice location:
  • Phone: 918-502-0630
  • Fax:
Mailing address:
  • Phone: 901-517-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number19266
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: