Provider Demographics
NPI:1871227801
Name:ROADY, KEVIN TODD
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:TODD
Last Name:ROADY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 WHISPERING RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-8607
Mailing Address - Country:US
Mailing Address - Phone:405-834-4265
Mailing Address - Fax:
Practice Address - Street 1:3401 N MAY AVE STE B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-6953
Practice Address - Country:US
Practice Address - Phone:405-843-6691
Practice Address - Fax:405-848-3591
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12215183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232840BMedicaid
OK100232840AMedicaid