Provider Demographics
NPI:1174283105
Name:PALMER, JEREMY F
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:F
Last Name:PALMER
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 1:908 W PARK PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-6442
Mailing Address - Country:US
Mailing Address - Phone:501-545-0475
Mailing Address - Fax:
Practice Address - Street 1:200 W CHOCTAW ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3808
Practice Address - Country:US
Practice Address - Phone:918-947-8180
Practice Address - Fax:918-251-2926
Is Sole Proprietor?:No
Enumeration Date:2021-12-17
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist