Provider Demographics
NPI:1164539623
Name:ADAMS, BRYAN D (DPH)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:D
Last Name:ADAMS
Suffix:
Gender:M
Credentials:DPH
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 971
Mailing Address - Street 2:
Mailing Address - City:MANNFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74044-0971
Mailing Address - Country:US
Mailing Address - Phone:918-865-2164
Mailing Address - Fax:
Practice Address - Street 1:124 COONROD AVE
Practice Address - Street 2:
Practice Address - City:MANNFORD
Practice Address - State:OK
Practice Address - Zip Code:74044-3437
Practice Address - Country:US
Practice Address - Phone:918-865-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist