Provider Demographics
NPI:1386086585
Name:LACKEY, KELSEY (PHARMD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:LACKEY
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 1:10117 S FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-6047
Mailing Address - Country:US
Mailing Address - Phone:620-330-7680
Mailing Address - Fax:
Practice Address - Street 1:4502 E 41ST ST
Practice Address - Street 2:SUITE 2H23
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2536
Practice Address - Country:US
Practice Address - Phone:918-660-3018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR-15309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist