=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477126043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARBY LYNN BALLESTERO PHARM.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2021
-----------------------------------------------------
Last Update Date | 07/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 HONOR HEIGHTS DR
-----------------------------------------------------
City | MUSKOGEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74401-1318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-577-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15646 E 114TH ST N
-----------------------------------------------------
City | OWASSO
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74055-6120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-409-7998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1835P0018X
-----------------------------------------------------
Taxonomy Name | Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
-----------------------------------------------------
License Number | 19243
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------