Provider Demographics
NPI:1124050042
Name:PICKETT, DAVID EUGENE (DPH)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:EUGENE
Last Name:PICKETT
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 1:417 BUENA VISTA
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521
Mailing Address - Country:US
Mailing Address - Phone:580-482-0158
Mailing Address - Fax:
Practice Address - Street 1:205 S PARK LN STE 110
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5733
Practice Address - Country:US
Practice Address - Phone:580-482-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK7962183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK7962OtherSTATE LICENSE NUMBER