MEDICARE: MR. EVERETT FRANKLIN LACY R.PH.

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	8358	OK

General Provider Information

NPI Number	:	1851669089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EVERETT FRANKLIN LACY R.PH.

Provider Business Mailing Address
First Line	:	1438 N LEWIS AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74110-4705
Country	:	US
Telephone Number	:	918-583-7593
Fax Number	:	918-583-0672

Provider Business Practice Location Address
First Line	:	1438 N LEWIS AVE.
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74110-4705
Country	:	US
Telephone Number	:	918-583-7593
Fax Number	:	918-583-0672

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

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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