Provider Demographics
NPI:1437710449
Name:CHARMASSON, MICKIE DEAN (PHARMACIST)
Entity Type:Individual
Prefix:MR
First Name:MICKIE
Middle Name:DEAN
Last Name:CHARMASSON
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 OKLAHOMA AVE
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-4258
Mailing Address - Country:US
Mailing Address - Phone:580-254-3504
Mailing Address - Fax:
Practice Address - Street 1:2116 OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-4258
Practice Address - Country:US
Practice Address - Phone:580-254-3504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9611183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK183500000XMedicaid