Provider Demographics
NPI:1538925474
Name:BLEYL, SHANNON MARIE (DPH)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:MARIE
Last Name:BLEYL
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:DR
Other - First Name:SHANNON
Other - Middle Name:MARIE
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPH
Mailing Address - Street 1:3227 S PIONEER ST
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-2394
Mailing Address - Country:US
Mailing Address - Phone:435-262-6019
Mailing Address - Fax:
Practice Address - Street 1:1027 E CHERRY ST
Practice Address - Street 2:
Practice Address - City:CUSHING
Practice Address - State:OK
Practice Address - Zip Code:74023-4101
Practice Address - Country:US
Practice Address - Phone:918-225-8392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK164091835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist