=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487444121
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIDY LEIGH MARSH PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2025
-----------------------------------------------------
Last Update Date | 05/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 S BLISS AVE
-----------------------------------------------------
City | TAHLEQUAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74464-2512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-458-3100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14206 E 150TH ST N
-----------------------------------------------------
City | COLLINSVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74021-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-978-9067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 20917
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------