Healthcare Provider Details

I. General information

NPI: 1386103190
Provider Name (Legal Business Name): AUSTIN WAYNE CRISSMAN PHARM.D, MBA, BCPS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

IV. Provider business mailing address

1011 14TH AVE NW
ARDMORE OK
73401-1828
US

V. Phone/Fax

Practice location:
  • Phone: 580-220-6704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License Number18919
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: