Provider Demographics
NPI:1174850457
Name:TANNER, LARTRESS ALBERT
Entity Type:Individual
Prefix:MR
First Name:LARTRESS
Middle Name:ALBERT
Last Name:TANNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 BRYANT IRVIN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3617
Mailing Address - Country:US
Mailing Address - Phone:817-292-5806
Mailing Address - Fax:817-292-5458
Practice Address - Street 1:4921 BRYANT IRVIN RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3617
Practice Address - Country:US
Practice Address - Phone:817-292-5806
Practice Address - Fax:817-292-5458
Is Sole Proprietor?:No
Enumeration Date:2009-11-07
Last Update Date:2009-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist