Provider Demographics
NPI:1669559746
Name:MCDONALD, JASON T
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:T
Last Name:MCDONALD
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 1:224 N SYCAMORE
Mailing Address - Street 2:PO BOX 92
Mailing Address - City:STRATFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74872-0150
Mailing Address - Country:US
Mailing Address - Phone:580-759-8860
Mailing Address - Fax:580-759-3233
Practice Address - Street 1:120 WEST MAIN
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:OK
Practice Address - Zip Code:74872-0150
Practice Address - Country:US
Practice Address - Phone:580-759-2312
Practice Address - Fax:580-759-3233
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12583183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist