Provider Demographics
NPI:1740779438
Name:TIEDEMAN, TANNER ALAN
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:ALAN
Last Name:TIEDEMAN
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 1:911 S AIR DEPOT BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110-4836
Mailing Address - Country:US
Mailing Address - Phone:405-737-3464
Mailing Address - Fax:405-737-9554
Practice Address - Street 1:911 S AIR DEPOT BLVD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4836
Practice Address - Country:US
Practice Address - Phone:405-737-3464
Practice Address - Fax:405-737-9554
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17544183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist