Provider Demographics
NPI:1811023120
Name:SOUTHERN, DEBORAH JEAN
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:SOUTHERN
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:P.O. BOX 485
Mailing Address - Street 2:
Mailing Address - City:CACHE
Mailing Address - State:OK
Mailing Address - Zip Code:73527-0485
Mailing Address - Country:US
Mailing Address - Phone:580-351-8626
Mailing Address - Fax:
Practice Address - Street 1:3401 W GORE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-6342
Practice Address - Country:US
Practice Address - Phone:580-250-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist