Provider Demographics
NPI:1881690105
Name:SANDERS, JEFFREY S (DPH)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:S
Last Name:SANDERS
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 1:22904 E 815 RD
Mailing Address - Street 2:
Mailing Address - City:WELLING
Mailing Address - State:OK
Mailing Address - Zip Code:74471-2073
Mailing Address - Country:US
Mailing Address - Phone:918-458-0928
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:918-775-4778
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10602183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist