Provider Demographics
NPI:1437234838
Name:DENNIS, JERRY LEE (DPH)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:LEE
Last Name:DENNIS
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 1:1116 FLYNN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNOKA
Mailing Address - State:OK
Mailing Address - Zip Code:73860-2525
Mailing Address - Country:US
Mailing Address - Phone:580-824-4881
Mailing Address - Fax:
Practice Address - Street 1:1549 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-2008
Practice Address - Country:US
Practice Address - Phone:580-824-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist