Provider Demographics
NPI:1104468271
Name:CRANDALL, TREY (PHARMD)
Entity type:Individual
Prefix:DR
First Name:TREY
Middle Name:
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4887 BEAUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:GROVES
Mailing Address - State:TX
Mailing Address - Zip Code:77619-6006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4225 GLADYS AVE STE B
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-3644
Practice Address - Country:US
Practice Address - Phone:409-898-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX53889183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX53889OtherTEXAS PHARMACY LICENSE NUMBER