Provider Demographics
NPI:1508009671
Name:HOLBROOK, TERRY WAYNE (DPH)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:WAYNE
Last Name:HOLBROOK
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 1:3409 W HARTFORD ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-2267
Mailing Address - Country:US
Mailing Address - Phone:918-625-3392
Mailing Address - Fax:918-234-7861
Practice Address - Street 1:1150 S GARNETT RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-1822
Practice Address - Country:US
Practice Address - Phone:918-437-9677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-19
Last Update Date:2009-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13357183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist