Organization
GREEN COUNTRY PHARMACY LLC
Active
Other names
COUNTRY MART PHARMACY
Organization subpart
No
Provider details
NPI number
Authorized official
BYRAN GREEN (PHCY MANG)
(918) 279-6600
Entity
Organization
Contact information
Practice address
13937 SOUTH HWY 51, COWETA, OK 74429
(918) 279-6600
(918) 279-6601
Mailing address
PO BOX 695, COWETA, OK 74429-0695
Taxonomy
Speciality
Code
Description
License number
State
3336C0003X
Community/Retail Pharmacy
Primary
38-5218
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200117070A
—
OK
01
—
2077136
PK
—
Enumeration date
07/23/2007
Last updated
07/29/2016
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