Provider Demographics
NPI:1033120498
Name:LUCKIE, JIM W (DPH)
Entity type:Individual
Prefix:
First Name:JIM
Middle Name:W
Last Name:LUCKIE
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 1:205 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:OKEENE
Mailing Address - State:OK
Mailing Address - Zip Code:73763-9335
Mailing Address - Country:US
Mailing Address - Phone:580-822-3789
Mailing Address - Fax:580-822-3136
Practice Address - Street 1:116 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:OKEENE
Practice Address - State:OK
Practice Address - Zip Code:73763
Practice Address - Country:US
Practice Address - Phone:580-822-3789
Practice Address - Fax:580-822-3136
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12644183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist