Provider Demographics
NPI:1528537230
Name:DEATHERAGE, LAUREN (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:
Last Name:DEATHERAGE
Suffix:
Gender:F
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:PO BOX 967
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-0967
Mailing Address - Country:US
Mailing Address - Phone:918-478-3002
Mailing Address - Fax:918-478-3017
Practice Address - Street 1:1201 S. LEE STREET
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434-7443
Practice Address - Country:US
Practice Address - Phone:918-478-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15189183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist