Provider Demographics
NPI:1033474465
Name:LEWIS, LARRY R (DPH)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:R
Last Name:LEWIS
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 1:8170 E 31ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-1717
Mailing Address - Country:US
Mailing Address - Phone:918-663-2560
Mailing Address - Fax:
Practice Address - Street 1:1631 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:OK
Practice Address - Zip Code:74350
Practice Address - Country:US
Practice Address - Phone:918-782-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8381183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist