Provider Demographics
NPI:1326143868
Name:DOUGLAS, KELLY EARL (DPH)
Entity Type:Individual
Prefix:MR
First Name:KELLY
Middle Name:EARL
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74058-2542
Mailing Address - Country:US
Mailing Address - Phone:918-762-3666
Mailing Address - Fax:918-762-2288
Practice Address - Street 1:539 6TH ST
Practice Address - Street 2:
Practice Address - City:PAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74058-2542
Practice Address - Country:US
Practice Address - Phone:918-762-3666
Practice Address - Fax:918-762-2288
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist