Provider Demographics
NPI:1609289453
Name:EDSALL, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EDSALL
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:PO BOX 811
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OK
Mailing Address - Zip Code:73724-0811
Mailing Address - Country:US
Mailing Address - Phone:580-886-4323
Mailing Address - Fax:580-886-2652
Practice Address - Street 1:411 E OAK
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OK
Practice Address - Zip Code:73724
Practice Address - Country:US
Practice Address - Phone:580-886-4323
Practice Address - Fax:580-886-2652
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist