MEDICARE: CHEYENNE PROFESSIONAL DRUG INC

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
1	3336C0004X	Compounding Pharmacy
2	333600000X	Pharmacy
3	3336C0003X	Community/Retail Pharmacy	35-5042	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2073244	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831122555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHEYENNE PROFESSIONAL DRUG INC

Provider Business Mailing Address
First Line	:	PO BOX 127
Second Line	:
City	:	SAYRE
State	:	OK
Zip	:	73662-0127
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	414 E WASHINGTON AVE
Second Line	:
City	:	SAYRE
State	:	OK
Zip	:	73662-1354
Country	:	US
Telephone Number	:	580-928-3323
Fax Number	:	580-928-3321

Authorized Official
Title or Position	:	PRESIDENT
Name	:	EDDIE LAKEY
Credential	:
Telephone Number	:	580-928-3323

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	07/13/2016

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Directions to “CHEYENNE PROFESSIONAL DRUG INC ” Practice Location

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