Provider Demographics
NPI:1497318240
Name:COLE, MICAH R
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:R
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1046
Mailing Address - Street 2:
Mailing Address - City:SEILING
Mailing Address - State:OK
Mailing Address - Zip Code:73663-1046
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:908 NW HWY 270 LONGHORN BUILDING STE A
Practice Address - Street 2:
Practice Address - City:SEILING
Practice Address - State:OK
Practice Address - Zip Code:73663
Practice Address - Country:US
Practice Address - Phone:580-922-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14283183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist