Provider Demographics
NPI:1053454157
Name:WOODSON, DARRELL WAYNE (DPH)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:WAYNE
Last Name:WOODSON
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 1:205 SW SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1518
Mailing Address - Country:US
Mailing Address - Phone:580-248-0300
Mailing Address - Fax:580-585-6513
Practice Address - Street 1:19305 NE CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-6125
Practice Address - Country:US
Practice Address - Phone:580-248-4367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist