Provider Demographics
NPI:1790271823
Name:LITTLE, JUSTIN LEVI (RPH)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LEVI
Last Name:LITTLE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10531 S KOA ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2382
Mailing Address - Country:US
Mailing Address - Phone:918-949-8310
Mailing Address - Fax:
Practice Address - Street 1:4636 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2908
Practice Address - Country:US
Practice Address - Phone:918-382-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14911183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK14911OtherSTATE LICENSE