Basic Information
| Provider Information | |||||||||
| NPI: | 1558432187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUDDERTH | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748202847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214570 | ||||||||
| FaxNumber: | 5804216283 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 CHICKASAW BLVD | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734011341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802268181 | ||||||||
| FaxNumber: | 5805590610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 07/24/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 12725 | OK | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | 12725 | 01 | OK | OK LICENSE | OTHER |