Healthcare Provider Details

I. General information

NPI: 1093305005
Provider Name (Legal Business Name): CHAZ K HURT DPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2021
Last Update Date: 01/23/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W. MAIN ST.
CARNEGIE OK
73015
US

IV. Provider business mailing address

620 S CAROL ST
CARNEGIE OK
73015-9064
US

V. Phone/Fax

Practice location:
  • Phone: 580-654-1111
  • Fax: 580-654-1229
Mailing address:
  • Phone: 580-515-2429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number18467
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: