Provider Demographics
NPI:1225498603
Name:MCCULLOUGH, BRIAN SHAWN (DPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:SHAWN
Last Name:MCCULLOUGH
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 1:1701 RENAISSANCE BLVD
Mailing Address - Street 2:STE. 120
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3086
Mailing Address - Country:US
Mailing Address - Phone:405-844-4978
Mailing Address - Fax:405-844-0562
Practice Address - Street 1:1701 RENAISSANCE BLVD
Practice Address - Street 2:STE. 120
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3086
Practice Address - Country:US
Practice Address - Phone:405-844-4978
Practice Address - Fax:405-844-0562
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist