Provider Demographics
NPI:1235411018
Name:MACHA, JEFFREY KEITH (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KEITH
Last Name:MACHA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3701
Mailing Address - Country:US
Mailing Address - Phone:918-298-2691
Mailing Address - Fax:918-298-2592
Practice Address - Street 1:210 S ELM ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3701
Practice Address - Country:US
Practice Address - Phone:918-298-2691
Practice Address - Fax:918-298-2592
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14260183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist