Provider Demographics
NPI:1831468198
Name:WOODARD, LESLIE RAY (RPH DPH)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:RAY
Last Name:WOODARD
Suffix:
Gender:M
Credentials:RPH DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1911 WINTERPARK DR
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-7600
Mailing Address - Country:US
Mailing Address - Phone:918-775-6521
Mailing Address - Fax:
Practice Address - Street 1:301 J T STITES BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-775-9159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11757183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist