Healthcare Provider Details

I. General information

NPI: 1467710269
Provider Name (Legal Business Name): BRIAN JACOB WELCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 1ST ST BLDG 46
ALTUS AFB OK
73523-5004
US

IV. Provider business mailing address

301 N 1ST ST BLDG 46
ALTUS AFB OK
73523-5004
US

V. Phone/Fax

Practice location:
  • Phone: 580-481-5600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPS 49342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: