Provider Demographics
NPI:1750937421
Name:SIMON, CHINNU ANN
Entity type:Individual
Prefix:
First Name:CHINNU
Middle Name:ANN
Last Name:SIMON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHINNU
Other - Middle Name:ANN
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5304 NW 117TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-2080
Mailing Address - Country:US
Mailing Address - Phone:405-339-3057
Mailing Address - Fax:
Practice Address - Street 1:1801 BELLE ISLE BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-4221
Practice Address - Country:US
Practice Address - Phone:405-841-6516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15508183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist