Healthcare Provider Details

I. General information

NPI: 1477754463
Provider Name (Legal Business Name): FOSTER CORNER DRUG INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 04/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 N 6TH ST
PERRY OK
73077-6607
US

IV. Provider business mailing address

328 N 6TH ST
PERRY OK
73077-6607
US

V. Phone/Fax

Practice location:
  • Phone: 580-336-2136
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number56-1529
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: TROY SIMONS
Title or Position: OWNER AND PHARMACIST
Credential:
Phone: 580-336-2136