Provider Demographics
NPI:1730252370
Name:CULLY, JOHN RODNEY (DPH)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RODNEY
Last Name:CULLY
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:MR
Other - First Name:JOHN
Other - Middle Name:RODNEY
Other - Last Name:CULLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPH
Mailing Address - Street 1:905 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-9205
Mailing Address - Country:US
Mailing Address - Phone:580-938-5127
Mailing Address - Fax:580-938-2498
Practice Address - Street 1:905 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858-9205
Practice Address - Country:US
Practice Address - Phone:580-938-5127
Practice Address - Fax:580-938-2498
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8823183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist