Ethan Garret Colwell
Individual provider Active NPI Pharmacist · Wagoner, OK
NPI 1114408010 · NPPES record last updated Aug 28, 2018
Key facts
- NPI
- 1114408010
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pharmacist 183500000X
- License
- 18071 (OK)
- Practice address
- 1305 W Cherokee St
Wagoner, OK 74467-4625 - Phone
- (918) 485-6688
- NPI assigned
- Aug 28, 2018
- Sex
- Male
- Sole proprietor
- No
Organizations & group practices 3
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 18071 | OK | MD | Pharmacist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| TMC Pharmacy Inc | Current | Accepting new patients | |
| Walgreen Co | Past | Accepting new patients | |
| Walgreen Co | Past |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 18071 | OK | Yes |
Addresses
Primary practice location
1305 W Cherokee St
Wagoner, OK 74467-4625
Mailing address
6681 N 431
Pryor, OK 74361-2395
Phone (918) 373-4626
Other providers in Wagoner, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Aug 28, 2018. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.