Healthcare Provider Details

I. General information

NPI: 1942215561
Provider Name (Legal Business Name): LAKE COUNTRY HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27753 S WELLING RD
WELLING OK
74471-2202
US

IV. Provider business mailing address

27753 S WELLING RD
WELLING OK
74471-2202
US

V. Phone/Fax

Practice location:
  • Phone: 918-457-9997
  • Fax: 918-457-5096
Mailing address:
  • Phone: 918-457-9997
  • Fax: 918-457-5096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number365591
License Number StateOK

VIII. Authorized Official

Name: MARSENA MCINTOSH
Title or Position: MANAGER
Credential:
Phone: 918-457-5535