Provider Demographics
NPI:1851673750
Name:INGMIRE, DARRELL G (DPH)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:G
Last Name:INGMIRE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7314 S FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7107
Mailing Address - Country:US
Mailing Address - Phone:918-523-9282
Mailing Address - Fax:
Practice Address - Street 1:4971 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-6914
Practice Address - Country:US
Practice Address - Phone:918-663-4578
Practice Address - Fax:918-663-2004
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist