Provider Demographics
NPI:1891807590
Name:MYERS, JEREMY LEE (DPH)
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:LEE
Last Name:MYERS
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 1:14004 E 136TH ST N
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3648
Mailing Address - Country:US
Mailing Address - Phone:918-491-9898
Mailing Address - Fax:
Practice Address - Street 1:6120 E 71ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6734
Practice Address - Country:US
Practice Address - Phone:918-491-9898
Practice Address - Fax:918-494-4793
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12347183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist