Provider Demographics
NPI:1750392114
Name:MCMILLIN, DAVID RAY (DPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:RAY
Last Name:MCMILLIN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 AUGUSTA DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8576
Mailing Address - Country:US
Mailing Address - Phone:580-332-0983
Mailing Address - Fax:580-332-7965
Practice Address - Street 1:312 W 12TH ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-6406
Practice Address - Country:US
Practice Address - Phone:580-332-8888
Practice Address - Fax:580-332-7965
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK11769OtherPHARMACIST LICENSE