Provider Demographics
NPI:1134723968
Name:CRANDELL, THOMAS TANNER
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:TANNER
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 1:2910 WHITE OAK
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-8797
Mailing Address - Country:US
Mailing Address - Phone:918-839-4588
Mailing Address - Fax:
Practice Address - Street 1:3108 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-5410
Practice Address - Country:US
Practice Address - Phone:918-647-2641
Practice Address - Fax:918-647-8131
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17004183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist