Provider Demographics
NPI:1780198713
Name:AUTRY, MARCUS TAD (PHARMD, BCPS)
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:TAD
Last Name:AUTRY
Suffix:
Gender:M
Credentials:PHARMD, BCPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-5712
Mailing Address - Country:US
Mailing Address - Phone:918-809-8526
Mailing Address - Fax:
Practice Address - Street 1:900 NE 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5420
Practice Address - Country:US
Practice Address - Phone:405-271-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK170011835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy