Provider Demographics
NPI:1073675732
Name:ALLEN, EDDIE D (DPH)
Entity Type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:D
Last Name:ALLEN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:659 S PARK DR
Mailing Address - Street 2:PO BOX 997
Mailing Address - City:BROKEN BOW
Mailing Address - State:OK
Mailing Address - Zip Code:74728-5331
Mailing Address - Country:US
Mailing Address - Phone:580-584-5841
Mailing Address - Fax:580-584-5845
Practice Address - Street 1:659 S PARK DR
Practice Address - Street 2:
Practice Address - City:BROKEN BOW
Practice Address - State:OK
Practice Address - Zip Code:74728-5331
Practice Address - Country:US
Practice Address - Phone:580-584-5841
Practice Address - Fax:580-584-5845
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist