Basic Information
| Provider Information | |||||||||
| NPI: | 1215537568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EDMONDSON | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHARMD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 935 S HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | SILOAM SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727613802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795499065 | ||||||||
| FaxNumber: | 4795499067 | ||||||||
| Practice Location | |||||||||
| Address1: | 935 S HOLLY ST | ||||||||
| Address2: | |||||||||
| City: | SILOAM SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727613802 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799579065 | ||||||||
| FaxNumber: | 4795499067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PD09375 | AR | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.