Provider Demographics
NPI:1811278302
Name:RALPH, DEREK EDWARD (PHARMD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:EDWARD
Last Name:RALPH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 E STATE HIGHWAY 152
Mailing Address - Street 2:
Mailing Address - City:MUSTANG
Mailing Address - State:OK
Mailing Address - Zip Code:73064-4402
Mailing Address - Country:US
Mailing Address - Phone:405-376-3751
Mailing Address - Fax:
Practice Address - Street 1:112 E STATE HIGHWAY 152
Practice Address - Street 2:
Practice Address - City:MUSTANG
Practice Address - State:OK
Practice Address - Zip Code:73064-4402
Practice Address - Country:US
Practice Address - Phone:405-376-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13778183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist