Provider Demographics
NPI:1528127958
Name:ROSS, LEE ALLEN (DPH)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ALLEN
Last Name:ROSS
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 MUIRFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-8580
Mailing Address - Country:US
Mailing Address - Phone:580-332-6050
Mailing Address - Fax:
Practice Address - Street 1:703 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3457
Practice Address - Country:US
Practice Address - Phone:580-421-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11134183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist