1639447378 NPI number — RYAN WOODY

Table of content: (NPI 1639447378)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639447378 NPI number — RYAN WOODY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RYAN WOODY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639447378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 77
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ERICK
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73645-0077
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-526-3311
Provider Business Mailing Address Fax Number:
580-526-3275

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 WEST ROGER MILLER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ERICK
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73645-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-526-3311
Provider Business Practice Location Address Fax Number:
580-526-3275
Provider Enumeration Date:
12/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WOODY
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER/MANAGER
Authorized Official Telephone Number:
580-526-3311

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X , with the licence number:  35-5804 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35-5804 . This is a "OKLAHOMA STATE BOARD OF PHARMACY" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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