Provider Demographics
NPI:1932797610
Name:YODER, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:YODER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-6821
Mailing Address - Country:US
Mailing Address - Phone:918-542-4444
Mailing Address - Fax:918-542-4441
Practice Address - Street 1:207 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:VINITA
Practice Address - State:OK
Practice Address - Zip Code:74301-3129
Practice Address - Country:US
Practice Address - Phone:918-256-3402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-07
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist