Provider Demographics
NPI:1861100604
Name:EDMONSON, WENDELL SHANE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:WENDELL
Middle Name:SHANE
Last Name:EDMONSON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:294 COUNTRY TYME DR
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65721-6503
Mailing Address - Country:US
Mailing Address - Phone:417-343-8484
Mailing Address - Fax:
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8362
Practice Address - Country:US
Practice Address - Phone:405-752-3034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001029138183500000X
OK12513183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist