Provider Demographics
NPI:1225534399
Name:WARNER, NICHOLAS (RPH)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WARNER
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S MUSTANG RD
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-6686
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 S MUSTANG RD
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6686
Practice Address - Country:US
Practice Address - Phone:405-324-8170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15438183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK15438OtherPHARMACIST LICENSE NUMBER