Provider Demographics
NPI:1750630513
Name:BLACK, SCOTTY RAY (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SCOTTY
Middle Name:RAY
Last Name:BLACK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7670 US HIGHWAY 377 S
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-4460
Mailing Address - Country:US
Mailing Address - Phone:580-371-5318
Mailing Address - Fax:
Practice Address - Street 1:7670 US HIGHWAY 377 S
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-4460
Practice Address - Country:US
Practice Address - Phone:580-371-5318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15142183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist