Provider Demographics
NPI:1134724230
Name:LEE, JERALD ANDREW
Entity type:Individual
Prefix:
First Name:JERALD
Middle Name:ANDREW
Last Name:LEE
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 1:24377 E 1006 RD
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:OK
Mailing Address - Zip Code:73096-5160
Mailing Address - Country:US
Mailing Address - Phone:580-890-7755
Mailing Address - Fax:
Practice Address - Street 1:510 N ARAPAHO AVE
Practice Address - Street 2:
Practice Address - City:HYDRO
Practice Address - State:OK
Practice Address - Zip Code:73048-8702
Practice Address - Country:US
Practice Address - Phone:405-663-4111
Practice Address - Fax:855-937-0796
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13718183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist