Provider Demographics
NPI:1538763313
Name:PORTER, LOUISE M
Entity type:Individual
Prefix:
First Name:LOUISE
Middle Name:M
Last Name:PORTER
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 1:1800 S WOOD DR
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-6826
Mailing Address - Country:US
Mailing Address - Phone:918-756-9646
Mailing Address - Fax:918-756-8829
Practice Address - Street 1:1800 S WOOD DR
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6826
Practice Address - Country:US
Practice Address - Phone:918-756-9646
Practice Address - Fax:918-756-8829
Is Sole Proprietor?:No
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist