Provider Demographics
NPI:1265130157
Name:STEWART, KODY ROSS (PHARMD)
Entity type:Individual
Prefix:
First Name:KODY
Middle Name:ROSS
Last Name:STEWART
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-1403
Mailing Address - Country:US
Mailing Address - Phone:580-436-0900
Mailing Address - Fax:580-332-2541
Practice Address - Street 1:1601 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-1403
Practice Address - Country:US
Practice Address - Phone:580-436-0900
Practice Address - Fax:580-332-2541
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19668183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist