Provider Demographics
NPI:1033200803
Name:RAZOOK, JACK (DPH)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:RAZOOK
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 1:1518 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-5468
Mailing Address - Country:US
Mailing Address - Phone:405-377-4445
Mailing Address - Fax:
Practice Address - Street 1:1518 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-5468
Practice Address - Country:US
Practice Address - Phone:405-377-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0334440001Medicare NSC