Provider Demographics
NPI:1871664318
Name:STICK, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:STICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:1007 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2847
Practice Address - Country:US
Practice Address - Phone:580-421-6260
Practice Address - Fax:580-559-0610
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4064183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4064OtherOK LICENSE