Provider Demographics
NPI:1487749081
Name:PINKERTON, MIKE B (DPH)
Entity type:Individual
Prefix:DR
First Name:MIKE
Middle Name:B
Last Name:PINKERTON
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 1:202 SOUTH SECOND
Mailing Address - Street 2:
Mailing Address - City:STILWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74960
Mailing Address - Country:US
Mailing Address - Phone:918-696-2500
Mailing Address - Fax:918-696-5556
Practice Address - Street 1:202 SOUTH SECOND
Practice Address - Street 2:
Practice Address - City:STILWELL
Practice Address - State:OK
Practice Address - Zip Code:74960
Practice Address - Country:US
Practice Address - Phone:918-696-2500
Practice Address - Fax:918-696-5556
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46-3613183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100233940AMedicaid
OK0240360001Medicare NSC