Provider Demographics
NPI:1669072047
Name:BLACK, LEA WILLIAMSON (PHARMACIST)
Entity type:Individual
Prefix:
First Name:LEA
Middle Name:WILLIAMSON
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3408 STATE HIGHWAY 37
Mailing Address - Street 2:
Mailing Address - City:GARVIN
Mailing Address - State:OK
Mailing Address - Zip Code:74736-5314
Mailing Address - Country:US
Mailing Address - Phone:580-212-8678
Mailing Address - Fax:
Practice Address - Street 1:1907 SE WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-5253
Practice Address - Country:US
Practice Address - Phone:580-286-3323
Practice Address - Fax:580-286-2396
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11827183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist