Provider Demographics
NPI:1346896032
Name:CULVER, DUSTY
Entity Type:Individual
Prefix:
First Name:DUSTY
Middle Name:
Last Name:CULVER
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 1:2415 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74354-2232
Mailing Address - Country:US
Mailing Address - Phone:918-542-8429
Mailing Address - Fax:918-542-8420
Practice Address - Street 1:2415 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-2232
Practice Address - Country:US
Practice Address - Phone:918-542-8429
Practice Address - Fax:918-542-8420
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11512183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist