Provider Demographics
NPI:1346478765
Name:TIDWELL, DARREN (DPH)
Entity Type:Individual
Prefix:
First Name:DARREN
Middle Name:
Last Name:TIDWELL
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 1:225 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILBURTON
Mailing Address - State:OK
Mailing Address - Zip Code:74578-4045
Mailing Address - Country:US
Mailing Address - Phone:918-465-9300
Mailing Address - Fax:918-465-9303
Practice Address - Street 1:225 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WILBURTON
Practice Address - State:OK
Practice Address - Zip Code:74578-4045
Practice Address - Country:US
Practice Address - Phone:918-465-9300
Practice Address - Fax:918-465-9303
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-24
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11475183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200081170BMedicaid
OK200081170AMedicaid
OK200081170BMedicaid