Provider Demographics
NPI:1598221467
Name:STOUT, JUSTIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:STOUT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12071 S STATE HIGHWAY 51
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-7136
Mailing Address - Country:US
Mailing Address - Phone:918-887-1040
Mailing Address - Fax:
Practice Address - Street 1:12071 S STATE HIGHWAY 51
Practice Address - Street 2:
Practice Address - City:COWETA
Practice Address - State:OK
Practice Address - Zip Code:74429-7136
Practice Address - Country:US
Practice Address - Phone:918-887-1040
Practice Address - Fax:918-279-0152
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14443183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist