Provider Demographics
NPI:1396013934
Name:PUCKETT, DANIEL J (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:PUCKETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134A ESTEP RDG
Mailing Address - Street 2:
Mailing Address - City:JOLO
Mailing Address - State:WV
Mailing Address - Zip Code:24850-9430
Mailing Address - Country:US
Mailing Address - Phone:304-920-9896
Mailing Address - Fax:
Practice Address - Street 1:134A ESTEP RDG
Practice Address - Street 2:
Practice Address - City:JOLO
Practice Address - State:WV
Practice Address - Zip Code:24850-9430
Practice Address - Country:US
Practice Address - Phone:304-920-9896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-11
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0203013583183500000X
WVIN0006370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist