Provider Demographics
NPI:1104851989
Name:CHEYENNE PROFESSIONAL DRUG, INC
Entity Type:Organization
Organization Name:CHEYENNE PROFESSIONAL DRUG, INC
Other - Org Name:SAYRE PROFESSIONAL PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:580-374-1615
Mailing Address - Street 1:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:OK
Mailing Address - Zip Code:73662-0111
Mailing Address - Country:US
Mailing Address - Phone:580-928-3633
Mailing Address - Fax:580-928-3635
Practice Address - Street 1:1002 NE HIGHWAY 66 STE 1
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:OK
Practice Address - Zip Code:73662-9312
Practice Address - Country:US
Practice Address - Phone:580-928-3633
Practice Address - Fax:580-928-3635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073595OtherPK
OK100244920AMedicaid
OK100244920AMedicaid