Healthcare Provider Details

I. General information

NPI: 1093362337
Provider Name (Legal Business Name): FOSTER CORNER DRUG LONG TERM CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
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: 580-336-9445
Mailing address:
  • Phone: 580-336-2136
  • Fax: 580-336-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: TROY SIMONS
Title or Position: PRESIDENT
Credential:
Phone: 405-372-4882