Provider Demographics
NPI:1992469316
Name:WILLIAMS, JERRY B (DPH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:B
Last Name:WILLIAMS
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 1:8647 S 79TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-6646
Mailing Address - Country:US
Mailing Address - Phone:918-688-8696
Mailing Address - Fax:
Practice Address - Street 1:6022 E 112TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-7714
Practice Address - Country:US
Practice Address - Phone:918-688-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11793183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist