Provider Demographics
NPI:1114062908
Name:WYATT, NATHAN SHANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:SHANE
Last Name:WYATT
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 1:1201 S BELMONT AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-6351
Mailing Address - Country:US
Mailing Address - Phone:918-756-9909
Mailing Address - Fax:918-756-2464
Practice Address - Street 1:1201 S BELMONT AVE
Practice Address - Street 2:BAKER BUILDING - SUITE 106
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447
Practice Address - Country:US
Practice Address - Phone:918-756-9909
Practice Address - Fax:918-756-2464
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK13255OtherOKLAHOMA PHARMACY LICENSE