Provider Demographics
NPI:1881618924
Name:PENDERGRAFT, TODD ERNEST (DPH)
Entity type:Individual
Prefix:MR
First Name:TODD
Middle Name:ERNEST
Last Name:PENDERGRAFT
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 1:3359 S ELM PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7924
Mailing Address - Country:US
Mailing Address - Phone:918-451-3784
Mailing Address - Fax:918-451-2295
Practice Address - Street 1:3359 S ELM PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7924
Practice Address - Country:US
Practice Address - Phone:918-451-3784
Practice Address - Fax:918-451-2295
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10995183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist