MEDICARE: MR. DAVID EUGENE PICKETT D.PH.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	7962	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7962	OTHER	OK	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1124050042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID EUGENE PICKETT D.PH.

Provider Business Mailing Address
First Line	:	417 BUENA VISTA
Second Line	:
City	:	ALTUS
State	:	OK
Zip	:	73521
Country	:	US
Telephone Number	:	580-482-0158
Fax Number	:

Provider Business Practice Location Address
First Line	:	205 S PARK LN STE 110
Second Line	:
City	:	ALTUS
State	:	OK
Zip	:	73521-5733
Country	:	US
Telephone Number	:	580-482-6464
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	07/08/2007

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