Provider Demographics
NPI:1639386188
Name:TIGERT, GARY LYLE (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LYLE
Last Name:TIGERT
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 WOODS LN
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1159
Mailing Address - Country:US
Mailing Address - Phone:580-223-1331
Mailing Address - Fax:580-223-4194
Practice Address - Street 1:35 TIFFANY PLZ STE C
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2526
Practice Address - Country:US
Practice Address - Phone:580-223-1331
Practice Address - Fax:580-223-4194
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8073183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist