Provider Demographics
NPI:1811908361
Name:DANDRIDGE, RICHARD ERNEST (DPH)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ERNEST
Last Name:DANDRIDGE
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 1:1607 SOUTH MUSKOGEE AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:918-456-2531
Mailing Address - Fax:918-456-2586
Practice Address - Street 1:1607 S MUSKOGEE AVE
Practice Address - Street 2:SUITE D
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-5440
Practice Address - Country:US
Practice Address - Phone:918-456-2531
Practice Address - Fax:918-456-2586
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12894183500000X
WV5316183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist