Provider Demographics
NPI:1790396380
Name:DOUGHAN, MAYA
Entity Type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:DOUGHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 N PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGE
Mailing Address - State:OK
Mailing Address - Zip Code:73120-3914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9401 N PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:THE VILLAGE
Practice Address - State:OK
Practice Address - Zip Code:73120-3914
Practice Address - Country:US
Practice Address - Phone:405-751-3553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-16
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13666183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist