Provider Demographics
NPI:1508924218
Name:MCGOUGH, ROBERT ALLEN (DPH)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ALLEN
Last Name:MCGOUGH
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 1:109 KERR AVENUE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-649-1100
Mailing Address - Fax:918-649-1102
Practice Address - Street 1:109 KERR AVENUE
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953
Practice Address - Country:US
Practice Address - Phone:918-649-1100
Practice Address - Fax:918-649-1102
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist