Provider Demographics
NPI:1982894739
Name:DEXTER, TANISHA CRYSTAL
Entity Type:Individual
Prefix:DR
First Name:TANISHA
Middle Name:CRYSTAL
Last Name:DEXTER
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 1:1202 EAST RICHARDS STREET
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633
Mailing Address - Country:US
Mailing Address - Phone:307-358-5088
Mailing Address - Fax:
Practice Address - Street 1:1202 EAST RICHARDS STREET
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633
Practice Address - Country:US
Practice Address - Phone:307-358-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist