Provider Demographics
NPI:1205817285
Name:MITCHELL, GARY WILLIS (DPH)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:WILLIS
Last Name:MITCHELL
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 1:905 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-9205
Mailing Address - Country:US
Mailing Address - Phone:580-938-2551
Mailing Address - Fax:580-938-2659
Practice Address - Street 1:905 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858-9205
Practice Address - Country:US
Practice Address - Phone:580-938-2551
Practice Address - Fax:580-938-2659
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8840183500000X
KS10455183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist