Healthcare Provider Details

I. General information

NPI: 1639575269
Provider Name (Legal Business Name): WELEETKA DRUG INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2014
Last Update Date: 10/11/2021
Certification Date: 10/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 W 9TH STREET
WELEETKA OK
74880-0727
US

IV. Provider business mailing address

PO BOX 727
WELEETKA OK
74880-0727
US

V. Phone/Fax

Practice location:
  • Phone: 405-786-2247
  • Fax: 405-786-2409
Mailing address:
  • Phone: 405-786-2247
  • Fax: 405-786-2409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number51-6952
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200564890A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier2148284
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: GALLEN SHENEMAN
Title or Position: PIC/DPH
Credential:
Phone: 405-786-2337