Provider Demographics
NPI:1174098941
Name:SEQUOYAH COUNTY DRUG COMPANY PLLC
Entity type:Organization
Organization Name:SEQUOYAH COUNTY DRUG COMPANY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:SELF
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-571-8813
Mailing Address - Street 1:PO BOX 705
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-0705
Mailing Address - Country:US
Mailing Address - Phone:918-571-8813
Mailing Address - Fax:
Practice Address - Street 1:1632 S KERR BLVD
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955
Practice Address - Country:US
Practice Address - Phone:918-774-0089
Practice Address - Fax:918-774-0890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-09
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200811470AMedicaid