Provider Demographics
NPI:1619035722
Name:NACTHIGALL, AL THARYN (DPH)
Entity Type:Individual
Prefix:
First Name:AL
Middle Name:THARYN
Last Name:NACTHIGALL
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:PO BOX 82
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-0082
Mailing Address - Country:US
Mailing Address - Phone:918-371-2547
Mailing Address - Fax:918-371-0268
Practice Address - Street 1:1205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3114
Practice Address - Country:US
Practice Address - Phone:918-371-2547
Practice Address - Fax:918-371-0268
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0454110001Medicare ID - Type Unspecified