Provider Demographics
NPI:1740880301
Name:BURKART, LARRY LANCE (DPH)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:LANCE
Last Name:BURKART
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 1:462041 E 1026 RD
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4075
Mailing Address - Country:US
Mailing Address - Phone:918-619-5362
Mailing Address - Fax:
Practice Address - Street 1:2020 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5439
Practice Address - Country:US
Practice Address - Phone:918-456-2437
Practice Address - Fax:918-456-2458
Is Sole Proprietor?:No
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12483183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist