Provider Demographics
NPI:1407317332
Name:RALEY, DARRYL LEON (RPH)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:LEON
Last Name:RALEY
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 1:108 S MORTON AVE
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-5022
Mailing Address - Country:US
Mailing Address - Phone:918-756-6488
Mailing Address - Fax:918-756-0638
Practice Address - Street 1:108 S MORTON AVE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-5022
Practice Address - Country:US
Practice Address - Phone:918-756-6488
Practice Address - Fax:918-756-0638
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist