Provider Demographics
NPI:1104426931
Name:WEATHERLY, CRYSTAL (DPH)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:WEATHERLY
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 NW SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-5296
Mailing Address - Country:US
Mailing Address - Phone:580-713-7160
Mailing Address - Fax:580-713-7163
Practice Address - Street 1:802 NW SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-5296
Practice Address - Country:US
Practice Address - Phone:580-713-7160
Practice Address - Fax:580-713-7163
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12333183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist