Provider Demographics
NPI:1164646097
Name:NEELY, SUSAN B (DPH)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:B
Last Name:NEELY
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1353 E 43RD PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-4141
Mailing Address - Country:US
Mailing Address - Phone:918-747-5932
Mailing Address - Fax:
Practice Address - Street 1:979 W WILL ROGERS BLVD
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-5040
Practice Address - Country:US
Practice Address - Phone:918-341-1184
Practice Address - Fax:918-341-6800
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8941183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist