Provider Demographics
NPI:1487254686
Name:BLACK, MOLLY RACHEL (DPH)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:RACHEL
Last Name:BLACK
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:RACHEL
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:106494 S 4230 RD
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-5837
Mailing Address - Country:US
Mailing Address - Phone:918-519-8885
Mailing Address - Fax:
Practice Address - Street 1:1312 E MAIN ST
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-2830
Practice Address - Country:US
Practice Address - Phone:918-967-3369
Practice Address - Fax:918-485-4461
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist