Provider Demographics
NPI:1538763875
Name:BOATMAN, BRYAN E (DPH)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:E
Last Name:BOATMAN
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 1:1137 CAMBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-3330
Mailing Address - Country:US
Mailing Address - Phone:405-517-4739
Mailing Address - Fax:405-350-2102
Practice Address - Street 1:948 S YUKON PKWY
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4589
Practice Address - Country:US
Practice Address - Phone:405-354-2582
Practice Address - Fax:405-350-2102
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10309183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist