Provider Demographics
NPI:1912129461
Name:CROUCH, KENNETH CODY (DPH)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:CODY
Last Name:CROUCH
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:MR
Other - First Name:CODY
Other - Middle Name:
Other - Last Name:CROUCH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPH
Mailing Address - Street 1:1501 W DEBBIE
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-1200
Mailing Address - Country:US
Mailing Address - Phone:580-225-2860
Mailing Address - Fax:
Practice Address - Street 1:1631 A EAST HWY 66
Practice Address - Street 2:
Practice Address - City:EL RENO
Practice Address - State:OK
Practice Address - Zip Code:73036
Practice Address - Country:US
Practice Address - Phone:405-262-7631
Practice Address - Fax:405-262-8099
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11888183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist