Provider Demographics
NPI:1942714597
Name:FOSTER, CARISSA ANN
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:ANN
Last Name:FOSTER
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 1:26409 E 136TH ST S
Mailing Address - Street 2:
Mailing Address - City:COWETA
Mailing Address - State:OK
Mailing Address - Zip Code:74429-5898
Mailing Address - Country:US
Mailing Address - Phone:918-361-4776
Mailing Address - Fax:
Practice Address - Street 1:4107 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2601
Practice Address - Country:US
Practice Address - Phone:918-747-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-17
Last Update Date:2017-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17130183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist