Provider Demographics
NPI:1669551057
Name:WOODSON, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WOODSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 NW CACHE RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3734
Mailing Address - Country:US
Mailing Address - Phone:580-353-7733
Mailing Address - Fax:580-585-6524
Practice Address - Street 1:3902 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3734
Practice Address - Country:US
Practice Address - Phone:580-353-7733
Practice Address - Fax:580-585-6524
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10473183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK4593520001Medicare ID - Type Unspecified