Provider Demographics
NPI:1679856819
Name:CARNEY, IDA SUE (DPH)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:SUE
Last Name:CARNEY
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:RR 1 BOX 182
Mailing Address - Street 2:
Mailing Address - City:COLONY
Mailing Address - State:OK
Mailing Address - Zip Code:73021-9752
Mailing Address - Country:US
Mailing Address - Phone:405-929-7661
Mailing Address - Fax:
Practice Address - Street 1:701 NW SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5202
Practice Address - Country:US
Practice Address - Phone:580-353-3948
Practice Address - Fax:580-353-6094
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12067183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist