Provider Demographics
NPI:1639575269
Name:WELEETKA DRUG INCORPORATED
Entity Type:Organization
Organization Name:WELEETKA DRUG INCORPORATED
Other - Org Name:WELEETKA DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PIC/DPH
Authorized Official - Prefix:
Authorized Official - First Name:GALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHENEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-786-2337
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:WELEETKA
Mailing Address - State:OK
Mailing Address - Zip Code:74880-0727
Mailing Address - Country:US
Mailing Address - Phone:405-786-2247
Mailing Address - Fax:405-786-2409
Practice Address - Street 1:309 W 9TH STREET
Practice Address - Street 2:
Practice Address - City:WELEETKA
Practice Address - State:OK
Practice Address - Zip Code:74880-0727
Practice Address - Country:US
Practice Address - Phone:405-786-2247
Practice Address - Fax:405-786-2409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-10
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X, 3336M0003X
OK51-69523336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200564890AMedicaid
2148284OtherPK