Provider Demographics
NPI:1356643936
Name:WEDMAN, JUSTIN MATTHEW (PHARM D)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MATTHEW
Last Name:WEDMAN
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N. LEE ST.
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-0967
Mailing Address - Country:US
Mailing Address - Phone:918-478-3002
Mailing Address - Fax:918-478-3017
Practice Address - Street 1:114 N. LEE ST.
Practice Address - Street 2:
Practice Address - City:FORT GIBSON
Practice Address - State:OK
Practice Address - Zip Code:74434
Practice Address - Country:US
Practice Address - Phone:918-478-3002
Practice Address - Fax:918-478-3017
Is Sole Proprietor?:No
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14818183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist