Provider Demographics
NPI:1134443492
Name:POFAHL, JIMMY R
Entity type:Individual
Prefix:
First Name:JIMMY
Middle Name:R
Last Name:POFAHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:916 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-1821
Mailing Address - Country:US
Mailing Address - Phone:918-371-6710
Mailing Address - Fax:
Practice Address - Street 1:501 SE WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-8232
Practice Address - Country:US
Practice Address - Phone:918-333-9140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2010-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8529183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist