Provider Demographics
NPI:1104393107
Name:AZZUN, ALICE KELUBIA (RPH)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:KELUBIA
Last Name:AZZUN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:DR
Other - First Name:ALICE
Other - Middle Name:KELUBIA
Other - Last Name:AZZUN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2407 OUTER RD APT 115
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:MO
Mailing Address - Zip Code:64804-7610
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:910 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-3317
Practice Address - Country:US
Practice Address - Phone:918-540-9544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-28
Last Update Date:2018-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18031183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist