Provider Demographics
NPI:1790290542
Name:MATHEW, PRAICY (PHARMD)
Entity Type:Individual
Prefix:
First Name:PRAICY
Middle Name:
Last Name:MATHEW
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 1:1008 PRESTON PARK DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-2173
Mailing Address - Country:US
Mailing Address - Phone:405-464-8828
Mailing Address - Fax:
Practice Address - Street 1:8917 NE 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73141-2245
Practice Address - Country:US
Practice Address - Phone:405-769-2712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17657183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist