Provider Demographics
NPI:1285146886
Name:POULTER, GINA LEA (PHARMD)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:LEA
Last Name:POULTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1949
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-1949
Mailing Address - Country:US
Mailing Address - Phone:918-266-8113
Mailing Address - Fax:
Practice Address - Street 1:2500 N HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:CATOOSA
Practice Address - State:OK
Practice Address - Zip Code:74015-2864
Practice Address - Country:US
Practice Address - Phone:918-266-8113
Practice Address - Fax:918-266-8138
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2017-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist