Provider Demographics
NPI:1740562867
Name:EDGE, MICHAEL H
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:H
Last Name:EDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 TEAL RIDGE LN
Mailing Address - Street 2:P.O. BOX 784
Mailing Address - City:KINGFISHER
Mailing Address - State:OK
Mailing Address - Zip Code:73750-3840
Mailing Address - Country:US
Mailing Address - Phone:405-375-6825
Mailing Address - Fax:
Practice Address - Street 1:929 WEST OWEN K. GARRIOTT RD.
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73703-5312
Practice Address - Country:US
Practice Address - Phone:580-237-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8866183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist