Provider Demographics
NPI:1699057067
Name:LUTTRELL, JERRY RAY (DPH)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:RAY
Last Name:LUTTRELL
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:RAY
Other - Last Name:LUTTRELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPH
Mailing Address - Street 1:3005 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:ANADARKO
Mailing Address - State:OK
Mailing Address - Zip Code:73005-6204
Mailing Address - Country:US
Mailing Address - Phone:405-247-9118
Mailing Address - Fax:
Practice Address - Street 1:3005 SHADY LN
Practice Address - Street 2:
Practice Address - City:ANADARKO
Practice Address - State:OK
Practice Address - Zip Code:73005-6204
Practice Address - Country:US
Practice Address - Phone:405-247-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8919183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK8919OtherPHARMACIST