Provider Demographics
NPI:1770178824
Name:HUMPHREYS, ELMER GENE III (PHARM D)
Entity type:Individual
Prefix:
First Name:ELMER
Middle Name:GENE
Last Name:HUMPHREYS
Suffix:III
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 ALMOND DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2405
Mailing Address - Country:US
Mailing Address - Phone:405-301-7681
Mailing Address - Fax:
Practice Address - Street 1:45 ALMOND DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2405
Practice Address - Country:US
Practice Address - Phone:405-301-7681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-01
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200862840AMedicaid