Provider Demographics
NPI:1568543726
Name:SHOUP, DEWEY W (DPH)
Entity Type:Individual
Prefix:DR
First Name:DEWEY
Middle Name:W
Last Name:SHOUP
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 1:14513 EDWARDS LOOP
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:OK
Mailing Address - Zip Code:74932-2099
Mailing Address - Country:US
Mailing Address - Phone:918-647-3137
Mailing Address - Fax:918-647-2977
Practice Address - Street 1:1940 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2638
Practice Address - Country:US
Practice Address - Phone:918-647-3137
Practice Address - Fax:918-647-2977
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8201183500000X
AR6196183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist