Provider Demographics
NPI:1619214525
Name:CRANDELL, ANDY
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:CRANDELL
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 1:401 E HIGHWAY 260
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541
Mailing Address - Country:US
Mailing Address - Phone:928-472-8242
Mailing Address - Fax:
Practice Address - Street 1:401 EAST HIGHWAY 260
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541
Practice Address - Country:US
Practice Address - Phone:928-472-8242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS019468183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist