Provider Demographics
NPI:1124344700
Name:WAYMIRE, JERRY W (DPH,PD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:W
Last Name:WAYMIRE
Suffix:
Gender:M
Credentials:DPH,PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2219 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-647-9531
Mailing Address - Fax:918-647-5247
Practice Address - Street 1:2219 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2007
Practice Address - Country:US
Practice Address - Phone:918-647-9531
Practice Address - Fax:918-647-5247
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9314183500000X
AR6548183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist