Provider Demographics
NPI:1134785793
Name:TANOE, BLED MARCHALL
Entity type:Individual
Prefix:
First Name:BLED
Middle Name:MARCHALL
Last Name:TANOE
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 1:4400 NW 23RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2644
Mailing Address - Country:US
Mailing Address - Phone:405-943-9899
Mailing Address - Fax:405-943-8994
Practice Address - Street 1:4400 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2644
Practice Address - Country:US
Practice Address - Phone:405-943-9899
Practice Address - Fax:405-943-8994
Is Sole Proprietor?:No
Enumeration Date:2019-05-18
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17017183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK361924025OtherTAX