Provider Demographics
NPI:1356941249
Name:ROYSTER, SUSAN E (DPH)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:E
Last Name:ROYSTER
Suffix:
Gender:F
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17816 GRIFFIN GATE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73012-9724
Mailing Address - Country:US
Mailing Address - Phone:580-262-1162
Mailing Address - Fax:
Practice Address - Street 1:200 STARLITE DR
Practice Address - Street 2:
Practice Address - City:KINGFISHER
Practice Address - State:OK
Practice Address - Zip Code:73750-4922
Practice Address - Country:US
Practice Address - Phone:405-375-5747
Practice Address - Fax:405-375-5727
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-29
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10922183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist