Provider Demographics
NPI:1760767313
Name:ENTERLINE, REX CHARLES (DPH)
Entity Type:Individual
Prefix:MR
First Name:REX
Middle Name:CHARLES
Last Name:ENTERLINE
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 1:4419 W PRINCETON PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9126
Mailing Address - Country:US
Mailing Address - Phone:918-693-2426
Mailing Address - Fax:918-742-2216
Practice Address - Street 1:3312 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135
Practice Address - Country:US
Practice Address - Phone:918-742-1058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10145183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist