Provider Demographics
NPI:1851611081
Name:DUBOSE, OKIE LEE JR (RPH)
Entity Type:Individual
Prefix:
First Name:OKIE
Middle Name:LEE
Last Name:DUBOSE
Suffix:JR
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 1:16872 OLYMPIC CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5153
Mailing Address - Country:US
Mailing Address - Phone:909-350-0033
Mailing Address - Fax:951-769-1594
Practice Address - Street 1:300 S HIGHLAND SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6504
Practice Address - Country:US
Practice Address - Phone:951-769-1285
Practice Address - Fax:951-769-1594
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44517183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist