Provider Demographics
NPI:1659842300
Name:MCENTIRE, CRYSTAL
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:
Last Name:MCENTIRE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 N 1710 RD
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:OK
Mailing Address - Zip Code:73666-6302
Mailing Address - Country:US
Mailing Address - Phone:806-203-0122
Mailing Address - Fax:
Practice Address - Street 1:108 W OKLAHOMA AVE
Practice Address - Street 2:
Practice Address - City:WHEELER
Practice Address - State:TX
Practice Address - Zip Code:79096-2416
Practice Address - Country:US
Practice Address - Phone:806-826-5561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13203183500000X
TX41469183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist