Provider Demographics
NPI:1437750601
Name:COLWELL, NATHAN JR (DPH)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:COLWELL
Suffix:JR
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 1:7525 N 439 RD
Mailing Address - Street 2:
Mailing Address - City:ADAIR
Mailing Address - State:OK
Mailing Address - Zip Code:74330-2222
Mailing Address - Country:US
Mailing Address - Phone:918-724-6283
Mailing Address - Fax:
Practice Address - Street 1:4901 S MILL ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-6837
Practice Address - Country:US
Practice Address - Phone:918-825-3663
Practice Address - Fax:918-825-4141
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17079183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist