Provider Demographics
NPI:1023020153
Name:GEORGE, ROY CHACKO (DPH)
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:CHACKO
Last Name:GEORGE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CAMELOT DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-1300
Mailing Address - Country:US
Mailing Address - Phone:405-350-1327
Mailing Address - Fax:
Practice Address - Street 1:4913 W RENO AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-6339
Practice Address - Country:US
Practice Address - Phone:405-948-4900
Practice Address - Fax:405-948-4929
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12464183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist