Provider Demographics
NPI:1003416694
Name:MCNEELY, MARISA NICOLE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:NICOLE
Last Name:MCNEELY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13530 N 130TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-4492
Mailing Address - Country:US
Mailing Address - Phone:918-639-9137
Mailing Address - Fax:
Practice Address - Street 1:700 W ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:SKIATOOK
Practice Address - State:OK
Practice Address - Zip Code:74070-1035
Practice Address - Country:US
Practice Address - Phone:918-396-3194
Practice Address - Fax:918-396-3211
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-01
Last Update Date:2020-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16472183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist