Provider Demographics
NPI:1417238478
Name:SHAW, BRIAN (DPH)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:SHAW
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 1:615 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-7062
Mailing Address - Country:US
Mailing Address - Phone:405-573-5019
Mailing Address - Fax:
Practice Address - Street 1:615 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73069-7062
Practice Address - Country:US
Practice Address - Phone:405-573-5019
Practice Address - Fax:405-573-9827
Is Sole Proprietor?:No
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12850183500000X
ARPD10715183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist