Healthcare Provider Details

I. General information

NPI: 1699599019
Provider Name (Legal Business Name): SUSAN WELLS PHARMACY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 N MAIN ST
BRISTOW OK
74010-2407
US

IV. Provider business mailing address

215 N MAIN ST
BRISTOW OK
74010-2407
US

V. Phone/Fax

Practice location:
  • Phone: 918-367-3391
  • Fax: 918-367-3392
Mailing address:
  • Phone: 918-367-3391
  • Fax: 918-367-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: SUSAN WELLS
Title or Position: PRESIDENT/PIC
Credential:
Phone: 918-367-3391