Provider Demographics
NPI:1417557109
Name:EADES, MARIBETH
Entity Type:Individual
Prefix:MRS
First Name:MARIBETH
Middle Name:
Last Name:EADES
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 1:5710 PECAN HILL CT
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-2073
Mailing Address - Country:US
Mailing Address - Phone:405-714-0239
Mailing Address - Fax:
Practice Address - Street 1:4545 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1523
Practice Address - Country:US
Practice Address - Phone:405-707-0756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10773183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist