Provider Demographics
NPI:1093595621
Name:OKI, REILLY THOMAS
Entity Type:Individual
Prefix:
First Name:REILLY
Middle Name:THOMAS
Last Name:OKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12370 HESPERIA RD STE 7
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4787
Mailing Address - Country:US
Mailing Address - Phone:760-843-7200
Mailing Address - Fax:
Practice Address - Street 1:12370 HESPERIA RD STE 7
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4787
Practice Address - Country:US
Practice Address - Phone:760-843-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA87404183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist