Provider Demographics
NPI:1124629456
Name:DAUGHERTY, CAREN
Entity type:Individual
Prefix:
First Name:CAREN
Middle Name:
Last Name:DAUGHERTY
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 1:124 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-9790
Mailing Address - Country:US
Mailing Address - Phone:580-243-9381
Mailing Address - Fax:
Practice Address - Street 1:210 REGIONAL DR
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-6472
Practice Address - Country:US
Practice Address - Phone:580-225-1575
Practice Address - Fax:580-225-8914
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist