Provider Demographics
NPI:1679126627
Name:LIVELY, WYATT EVANS (DPH)
Entity type:Individual
Prefix:MR
First Name:WYATT
Middle Name:EVANS
Last Name:LIVELY
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-2702
Mailing Address - Country:US
Mailing Address - Phone:918-273-3825
Mailing Address - Fax:918-273-2251
Practice Address - Street 1:128 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-2702
Practice Address - Country:US
Practice Address - Phone:918-273-3825
Practice Address - Fax:918-273-2251
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK183273336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy