Provider Demographics
NPI:1083951248
Name:FRASER, JERRY DAVID (DPH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DAVID
Last Name:FRASER
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 1:1101 HONOR HEIGHTS DR
Mailing Address - Street 2:PHARMACY DEPARTMENT
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-1302
Mailing Address - Country:US
Mailing Address - Phone:918-577-3185
Mailing Address - Fax:918-577-4463
Practice Address - Street 1:1101 HONOR HEIGHTS DR
Practice Address - Street 2:PHARMACY DEPARTMENT
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1302
Practice Address - Country:US
Practice Address - Phone:918-577-3185
Practice Address - Fax:918-577-4463
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-08
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK97651835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist