Provider Demographics
NPI:1477631513
Name:GLN OF MCALESTER, INC
Entity Type:Organization
Organization Name:GLN OF MCALESTER, INC
Other - Org Name:COUNTRY MART PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:STINCHCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:918-423-2980
Mailing Address - Street 1:601 E WYANDOTTE AVE
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-5425
Mailing Address - Country:US
Mailing Address - Phone:918-423-2980
Mailing Address - Fax:918-423-4736
Practice Address - Street 1:601 E WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5425
Practice Address - Country:US
Practice Address - Phone:918-423-2980
Practice Address - Fax:918-423-4736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13390183500000X
OK10833183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100243460AMedicaid
OK6373660001Medicare NSC