Provider Demographics
NPI:1245384361
Name:WYATT, BERNIE B
Entity Type:Individual
Prefix:
First Name:BERNIE
Middle Name:B
Last Name:WYATT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-2608
Mailing Address - Country:US
Mailing Address - Phone:918-623-1036
Mailing Address - Fax:918-623-0238
Practice Address - Street 1:324 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2608
Practice Address - Country:US
Practice Address - Phone:918-623-1771
Practice Address - Fax:918-623-0238
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8862183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist