Provider Demographics
NPI:1891397436
Name:FAIRWEATHER, CORBIN
Entity Type:Individual
Prefix:
First Name:CORBIN
Middle Name:
Last Name:FAIRWEATHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:FAIRWEATHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9320 N PENNSYLVANIA PL
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGE
Mailing Address - State:OK
Mailing Address - Zip Code:73120-1519
Mailing Address - Country:US
Mailing Address - Phone:405-840-2105
Mailing Address - Fax:405-840-1731
Practice Address - Street 1:9320 N PENNSYLVANIA PL
Practice Address - Street 2:
Practice Address - City:THE VILLAGE
Practice Address - State:OK
Practice Address - Zip Code:73120-1519
Practice Address - Country:US
Practice Address - Phone:405-840-2105
Practice Address - Fax:405-840-1731
Is Sole Proprietor?:No
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist