Provider Demographics
NPI:1215537782
Name:GENTRY, JEREMY WADE (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:WADE
Last Name:GENTRY
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 1:4720 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-2109
Mailing Address - Country:US
Mailing Address - Phone:918-392-7025
Mailing Address - Fax:918-392-7029
Practice Address - Street 1:4720 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-2109
Practice Address - Country:US
Practice Address - Phone:918-392-7025
Practice Address - Fax:918-392-7029
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65507183500000X
OK17997183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist