Provider Demographics
NPI:1245261973
Name:BUCKMASTER, EARL J (DPH)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:J
Last Name:BUCKMASTER
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:PO BOX 4640
Mailing Address - Street 2:10911 NE 23RD ST
Mailing Address - City:NICOMA PARK
Mailing Address - State:OK
Mailing Address - Zip Code:73066-4640
Mailing Address - Country:US
Mailing Address - Phone:405-769-3337
Mailing Address - Fax:405-769-3632
Practice Address - Street 1:10911 NE 23RD ST.
Practice Address - Street 2:
Practice Address - City:NICOMA PARK
Practice Address - State:OK
Practice Address - Zip Code:73066-4640
Practice Address - Country:US
Practice Address - Phone:405-769-3337
Practice Address - Fax:405-769-3632
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13627183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK730761074Medicare ID - Type UnspecifiedPART B BILLING ID NUMBER
OK3701554Medicare UPIN