Provider Demographics
NPI:1689886665
Name:LIEDTKE, MICHELLE DIANNE (PHARMD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:LIEDTKE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:OU COLLEGE OF PHARMACY
Mailing Address - Street 2:1110 N. STONEWALL AVE, CPB 206
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1223
Mailing Address - Country:US
Mailing Address - Phone:405-271-6878
Mailing Address - Fax:405-271-6430
Practice Address - Street 1:OU COLLEGE OF PHARMACY
Practice Address - Street 2:1110 N. STONEWALL AVE, CPB 206
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73117-1223
Practice Address - Country:US
Practice Address - Phone:405-271-6878
Practice Address - Fax:405-271-6430
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK127271835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy