Provider Demographics
NPI:1487704706
Name:DEBBIE JO LEWIS
Entity type:Organization
Organization Name:DEBBIE JO LEWIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-794-3565
Mailing Address - Street 1:322 N SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-4945
Mailing Address - Country:US
Mailing Address - Phone:405-794-3565
Mailing Address - Fax:405-794-0112
Practice Address - Street 1:322 N SERVICE RD
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:OK
Practice Address - Zip Code:73160-4945
Practice Address - Country:US
Practice Address - Phone:405-794-3565
Practice Address - Fax:405-794-0112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK7-45003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2072967OtherPK
OK100233300AMedicaid