Provider Demographics
NPI:1699903468
Name:BECKER, LISA DIANE (DPH)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANE
Last Name:BECKER
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 TIMBERCREST RD
Mailing Address - Street 2:
Mailing Address - City:CATOOSA
Mailing Address - State:OK
Mailing Address - Zip Code:74015-2314
Mailing Address - Country:US
Mailing Address - Phone:918-855-7677
Mailing Address - Fax:
Practice Address - Street 1:101 S MOORE AVE
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5047
Practice Address - Country:US
Practice Address - Phone:918-342-6589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist