Provider Demographics
NPI:1083303820
Name:BOSTICK, TANNER WEST (PHARMD)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:WEST
Last Name:BOSTICK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3902 CIMARRON BLVD APT 1204
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-4282
Mailing Address - Country:US
Mailing Address - Phone:903-413-2245
Mailing Address - Fax:
Practice Address - Street 1:5601 SARATOGA BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-4109
Practice Address - Country:US
Practice Address - Phone:361-980-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist