Provider Demographics
NPI:1023189388
Name:JUSTICE, JACK LEE (DPH)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:LEE
Last Name:JUSTICE
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 1:110 BURR AVE
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-3848
Mailing Address - Country:US
Mailing Address - Phone:405-238-7391
Mailing Address - Fax:405-238-1162
Practice Address - Street 1:110 BURR AVE
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-3848
Practice Address - Country:US
Practice Address - Phone:405-238-7391
Practice Address - Fax:405-238-1162
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8244183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist