Provider Demographics
NPI:1831731991
Name:TISDALE, BRIGETTE SHARIE (REGISTERED PHARMACIS)
Entity type:Individual
Prefix:
First Name:BRIGETTE
Middle Name:SHARIE
Last Name:TISDALE
Suffix:
Gender:F
Credentials:REGISTERED PHARMACIS
Other - Prefix:
Other - First Name:BRIGETTE
Other - Middle Name:SHARIE
Other - Last Name:TISDALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:REGISTERED PHARMACIS
Mailing Address - Street 1:2700 CENTRAL FWY
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76306-2843
Mailing Address - Country:US
Mailing Address - Phone:940-855-2374
Mailing Address - Fax:
Practice Address - Street 1:2700 CENTRAL FWY
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76306-2843
Practice Address - Country:US
Practice Address - Phone:940-855-2374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34945183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX34945OtherSTATE BOARD OF TEXAS