Provider Demographics
NPI:1417203316
Name:PANTOJA, LUIS ALBERTO (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ALBERTO
Last Name:PANTOJA
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 1:4500 S SHIELDS BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73129-3206
Mailing Address - Country:US
Mailing Address - Phone:405-631-3561
Mailing Address - Fax:405-631-7810
Practice Address - Street 1:4500 S SHIELDS BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-3206
Practice Address - Country:US
Practice Address - Phone:405-631-3561
Practice Address - Fax:405-631-7810
Is Sole Proprietor?:No
Enumeration Date:2012-07-28
Last Update Date:2012-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15245183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist