Provider Demographics
NPI:1033469606
Name:OLDACRE, MATT LANCE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:LANCE
Last Name:OLDACRE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 S. WILSON
Mailing Address - Street 2:
Mailing Address - City:VINITA
Mailing Address - State:OK
Mailing Address - Zip Code:74301
Mailing Address - Country:US
Mailing Address - Phone:918-323-0191
Mailing Address - Fax:
Practice Address - Street 1:525 S. WILSON
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301
Practice Address - Country:US
Practice Address - Phone:918-323-0191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-11
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15218183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist