Provider Demographics
NPI:1750974523
Name:NGO, LEROY
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:
Last Name:NGO
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 1:2113 COX LN
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-3426
Mailing Address - Country:US
Mailing Address - Phone:405-314-0310
Mailing Address - Fax:
Practice Address - Street 1:10717 N MAY AVE STE D
Practice Address - Street 2:
Practice Address - City:THE VILLAGE
Practice Address - State:OK
Practice Address - Zip Code:73120-2622
Practice Address - Country:US
Practice Address - Phone:405-451-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-12
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist