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Organization
LAKE COUNTRY HEALTHCARE LLC
Active
Organization
LAKE COUNTRY HEALTHCARE LLC
Active
Other names
LAKE COUNTRY HEALTHCARE LLC
Organization subpart
No
Provider details
NPI number
Authorized official
MARSENA MCINTOSH (MANAGER)
(918) 457-5535
Entity
Organization
Contact information
Practice address
27753 S WELLING RD, WELLING, OK 74471-2202
(918) 457-9997
(918) 457-5096
Mailing address
27753 S WELLING RD, WELLING, OK 74471-2202
(918) 457-9997
(918) 457-5096
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
NULL
3336L0003X
Long Term Care Pharmacy
Primary
365591
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200008180A
—
OK
01
—
3723625
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
07/30/2006
Last updated
12/16/2011
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