Provider Demographics
NPI:1790095198
Name:KING, ERICA SHAYE (PHARM D)
Entity Type:Individual
Prefix:MRS
First Name:ERICA
Middle Name:SHAYE
Last Name:KING
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S LYNN RIGGS BLVD
Mailing Address - Street 2:PMB #256
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-7814
Mailing Address - Country:US
Mailing Address - Phone:918-671-1308
Mailing Address - Fax:
Practice Address - Street 1:900 N OWEN WALTERS BLVD
Practice Address - Street 2:
Practice Address - City:SALINA
Practice Address - State:OK
Practice Address - Zip Code:74365-5003
Practice Address - Country:US
Practice Address - Phone:918-434-8507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist