Provider Demographics
NPI:1922153923
Name:NEWCOMB, CARLOS RALPH (DPH)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:RALPH
Last Name:NEWCOMB
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:PO BOX 1775
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:OK
Mailing Address - Zip Code:73601-0536
Mailing Address - Country:US
Mailing Address - Phone:580-323-5177
Mailing Address - Fax:
Practice Address - Street 1:915 FRISCO AVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:OK
Practice Address - Zip Code:73601-3324
Practice Address - Country:US
Practice Address - Phone:580-323-2020
Practice Address - Fax:580-323-3108
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0280780001Medicare ID - Type UnspecifiedMEDICARE RX