Provider Demographics
NPI:1154606051
Name:RILEY, CAROLYN JEAN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:JEAN
Last Name:RILEY
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 1:5700 NW 115TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-3544
Mailing Address - Country:US
Mailing Address - Phone:405-728-3911
Mailing Address - Fax:
Practice Address - Street 1:7101 W HEFNER RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-4503
Practice Address - Country:US
Practice Address - Phone:405-773-0711
Practice Address - Fax:405-773-1204
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8767183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist