Provider Demographics
NPI:1013518489
Name:THOMPSON, ANDREA LYNN
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN
Last Name:THOMPSON
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 1:1100 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-3900
Mailing Address - Country:US
Mailing Address - Phone:580-795-3358
Mailing Address - Fax:580-795-2390
Practice Address - Street 1:1100 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MADILL
Practice Address - State:OK
Practice Address - Zip Code:73446-3900
Practice Address - Country:US
Practice Address - Phone:580-795-3358
Practice Address - Fax:580-795-2390
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12223183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist