Provider Demographics
NPI:1285387662
Name:FORTSON, JOE BRENT
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:BRENT
Last Name:FORTSON
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:PO BOX 781
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-0781
Mailing Address - Country:US
Mailing Address - Phone:580-579-8497
Mailing Address - Fax:580-326-3910
Practice Address - Street 1:1911 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4249
Practice Address - Country:US
Practice Address - Phone:580-326-7541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11961183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist