Provider Demographics
NPI:1427652783
Name:WADLEY, TERRI L (DPH)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:L
Last Name:WADLEY
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 1:2115 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-5327
Mailing Address - Country:US
Mailing Address - Phone:918-786-4491
Mailing Address - Fax:
Practice Address - Street 1:2115 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5327
Practice Address - Country:US
Practice Address - Phone:918-786-4491
Practice Address - Fax:918-796-2043
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10968183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist