Provider Demographics
NPI:1851629216
Name:TISDALE, FLORA JEAN
Entity type:Individual
Prefix:
First Name:FLORA
Middle Name:JEAN
Last Name:TISDALE
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 1:5280 BUFFALO SPEEDWAY
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-4204
Mailing Address - Country:US
Mailing Address - Phone:713-838-7704
Mailing Address - Fax:
Practice Address - Street 1:5280 BUFFALO SPEEDWAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-4204
Practice Address - Country:US
Practice Address - Phone:713-838-7704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19077183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist