Provider Demographics
NPI:1528143815
Name:EDGEMAN HEALTH LLC
Entity type:Organization
Organization Name:EDGEMAN HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:580-916-5168
Mailing Address - Street 1:311 N. WASHINGTON AVE.
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701
Mailing Address - Country:US
Mailing Address - Phone:580-924-3784
Mailing Address - Fax:580-920-0048
Practice Address - Street 1:311 N. WASHINGTON AVE.
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701
Practice Address - Country:US
Practice Address - Phone:580-924-3784
Practice Address - Fax:580-920-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27-43933336C0003X, 3336C0003X
3336C0004X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074715OtherPK
OK100242910AMedicaid
OK5TS-15286924-05OtherSTATE SALES TAX