Provider Demographics
NPI:1376546960
Name:LAKE COUNTRY MEDICAL SUPPLIES OF OKMULGEE, LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY MEDICAL SUPPLIES OF OKMULGEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RITTER
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-889-7800
Mailing Address - Street 1:702 S MISSISSIPPI AVE
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-3324
Mailing Address - Country:US
Mailing Address - Phone:580-889-7878
Mailing Address - Fax:580-889-8713
Practice Address - Street 1:1180 S BELMONT AVE
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-6308
Practice Address - Country:US
Practice Address - Phone:918-756-9279
Practice Address - Fax:918-756-2656
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-27
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK332B00000X
332BD1200X, 332BN1400X, 332BP3500X
OK14-S-795332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100812630AMedicaid
OK100812630AMedicaid
OK1278730001Medicare ID - Type UnspecifiedREGION C MEDICARE