Provider Demographics
NPI:1770817595
Name:SMITH, JERRY J (DPH)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:J
Last Name:SMITH
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 1:402 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4815
Mailing Address - Country:US
Mailing Address - Phone:918-207-7071
Mailing Address - Fax:
Practice Address - Street 1:RR 2 BOX 93
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960
Practice Address - Country:US
Practice Address - Phone:918-696-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8893183500000X
KS9041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist