Provider Demographics
NPI:1750370292
Name:CRISSMAN, TERRY WAYNE (DPH)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:WAYNE
Last Name:CRISSMAN
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 6 BOX 310A
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-9210
Mailing Address - Country:US
Mailing Address - Phone:580-252-2255
Mailing Address - Fax:
Practice Address - Street 1:1407 N WHISENANT DR
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1650
Practice Address - Country:US
Practice Address - Phone:580-251-8786
Practice Address - Fax:580-251-8789
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8713183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist