MEDICARE: DR. LAUREN DEATHERAGE PHARM D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	15189	OK

General Provider Information

NPI Number	:	1528537230
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAUREN DEATHERAGE PHARM D

Provider Business Mailing Address
First Line	:	PO BOX 967
Second Line	:
City	:	FORT GIBSON
State	:	OK
Zip	:	74434-0967
Country	:	US
Telephone Number	:	918-478-3002
Fax Number	:	918-478-3017

Provider Business Practice Location Address
First Line	:	1201 S. LEE STREET
Second Line	:
City	:	FORT GIBSON
State	:	OK
Zip	:	74434-7443
Country	:	US
Telephone Number	:	918-478-3002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/26/2018
Last Update Date	:	11/26/2018

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