Provider Demographics
NPI:1639447378
Name:RYAN WOODY
Entity type:Organization
Organization Name:RYAN WOODY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WOODY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:580-526-3311
Mailing Address - Street 1:PO BOX 77
Mailing Address - Street 2:
Mailing Address - City:ERICK
Mailing Address - State:OK
Mailing Address - Zip Code:73645-0077
Mailing Address - Country:US
Mailing Address - Phone:580-526-3311
Mailing Address - Fax:580-526-3275
Practice Address - Street 1:215 WEST ROGER MILLER BLVD
Practice Address - Street 2:
Practice Address - City:ERICK
Practice Address - State:OK
Practice Address - Zip Code:73645-0000
Practice Address - Country:US
Practice Address - Phone:580-526-3311
Practice Address - Fax:580-526-3275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK35-58043336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK35-5804OtherOKLAHOMA STATE BOARD OF PHARMACY