# LAKE COUNTRY HEALTHCARE LLC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** LAKE COUNTRY HEALTHCARE LLC
- **Organization subpart:** No

## Provider details

- **NPI number:** 1942215561
- **Authorized official:** MARSENA MCINTOSH (MANAGER)
- **Authorized official phone:** (918) 457-5535

## Contact information

- **Practice address:** 27753 S WELLING RD, WELLING, OK 74471-2202
- **Practice address phone:** (918) 457-9997
- **Practice address fax:** (918) 457-5096
- **Mailing address:** 27753 S WELLING RD, WELLING, OK 74471-2202
- **Mailing address phone:** (918) 457-9997
- **Mailing address fax:** (918) 457-5096

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 333600000X | Pharmacy | — | NULL | — |
| 3336L0003X | Long Term Care Pharmacy | 365591 | OK | Yes |

## Other

- **Enumeration date:** 07/30/2006
- **Last updated:** 12/16/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200008180A | — | OK |
| 01 | — | 3723625 | NCPDP PROVIDER IDENTIFICATION NUMBER | — |