Provider Demographics
NPI:1659485118
Name:MALONE, AMOS (DPH)
Entity type:Individual
Prefix:
First Name:AMOS
Middle Name:
Last Name:MALONE
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:AMOS
Other - Middle Name:
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCN
Mailing Address - Street 1:2430 CHOCTAW DR
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-6565
Mailing Address - Country:US
Mailing Address - Phone:405-454-2476
Mailing Address - Fax:405-454-3507
Practice Address - Street 1:2060 N CHURCH AVE
Practice Address - Street 2:
Practice Address - City:HARRAH
Practice Address - State:OK
Practice Address - Zip Code:73045-0247
Practice Address - Country:US
Practice Address - Phone:405-454-2477
Practice Address - Fax:405-454-3507
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK 8116183500000X
OK37391835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered183500000XPharmacy Service ProvidersPharmacist
Not Answered1835N1003XPharmacy Service ProvidersPharmacistNutrition Support