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NPI Code Detail

MEDICARE: LAKE COUNTRY MEDICAL SUPPLIES, LLC

MEDICARE: LAKE COUNTRY MEDICAL SUPPLIES, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332B00000XDurable Medical Equipment & Medical SuppliesOK
2332BD1200XDialysis Equipment & Supplies (DME)
3332BN1400XNursing Facility Supplies (DME)
4332BP3500XParenteral & Enteral Nutrition Supplies (DME)
5332BX2000XOxygen Equipment & Supplies (DME)57-S-940OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2742803495001OTHEROKBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1114920816
Entity Type Code : Organization
Provider Name (Legal Business Name) : LAKE COUNTRY MEDICAL SUPPLIES, LLC
Provider Business Mailing Address
First Line : 744 S MISSISSIPPI AVE
Second Line :
City : ATOKA
State : OK
Zip : 74525-3355
Country : US
Telephone Number : 580-889-7878
Fax Number : 580-889-8713
Provider Business Practice Location Address
First Line : 744 S MISSISSIPPI AVE
Second Line :
City : ATOKA
State : OK
Zip : 74525-3355
Country : US
Telephone Number : 580-889-7878
Fax Number :
Authorized Official
Title or Position : OWNER
Name : VICTOR CLAY
Credential :
Telephone Number : 580-286-5022
Provider Enumeration Date : 05/27/2005
Last Update Date : 06/25/2019

Similar Medicare Providers

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744 S MISSISSIPPI AVE
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74525-3355
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1679172274 — MISS CYNTHIA ANN RIFFE RPH
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ATOKA, OK
74525-3355
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1700578853 — RITTER EXPRESS PHARMACY, INC
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1801896709 — NOEL W. EMERSON D.O.
Practice Location Address:
1510 S VIRGINIA AVE
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74525-3246
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Directions to “LAKE COUNTRY MEDICAL SUPPLIES, LLC ” Practice Location

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