Provider Demographics
NPI:1962049635
Name:TAYLOR, JACK BRYAN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:BRYAN
Last Name:TAYLOR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2029 GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9005
Mailing Address - Country:US
Mailing Address - Phone:405-878-5859
Mailing Address - Fax:405-214-4230
Practice Address - Street 1:2029 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9005
Practice Address - Country:US
Practice Address - Phone:405-878-5859
Practice Address - Fax:405-214-4230
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17050183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist