Provider Demographics
NPI:1760949622
Name:GASAWAY, COURTNEY RAE (PHARMD)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:RAE
Last Name:GASAWAY
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 1:1602 N GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PURCELL
Mailing Address - State:OK
Mailing Address - Zip Code:73080-1626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1602 N GREEN AVE
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-1626
Practice Address - Country:US
Practice Address - Phone:405-527-5900
Practice Address - Fax:405-527-0806
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13825183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235190AMedicaid