Provider Demographics
NPI:1114408010
Name:COLWELL, ETHAN GARRET
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:GARRET
Last Name:COLWELL
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 1:6681 N 431
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-2395
Mailing Address - Country:US
Mailing Address - Phone:918-373-4626
Mailing Address - Fax:
Practice Address - Street 1:1305 W CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4625
Practice Address - Country:US
Practice Address - Phone:918-485-6688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18071183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist