Provider Demographics
NPI:1508472481
Name:DE SANTIAGO, FABIAN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:FABIAN
Middle Name:
Last Name:DE SANTIAGO
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 S HIGHWAY 97
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-3812
Mailing Address - Country:US
Mailing Address - Phone:918-245-6661
Mailing Address - Fax:
Practice Address - Street 1:4016 S HIGHWAY 97
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-3812
Practice Address - Country:US
Practice Address - Phone:918-245-6661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18931183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist