Provider Demographics
NPI:1689610172
Name:SUSAN WELLS PHARMACY INC
Entity Type:Organization
Organization Name:SUSAN WELLS PHARMACY INC
Other - Org Name:KEMP DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER AND PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-367-3391
Mailing Address - Street 1:215 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-2407
Mailing Address - Country:US
Mailing Address - Phone:918-367-3391
Mailing Address - Fax:918-367-3392
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRISTOW
Practice Address - State:OK
Practice Address - Zip Code:74010-2407
Practice Address - Country:US
Practice Address - Phone:918-367-3391
Practice Address - Fax:918-367-3392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336C0004X
OK11-50633336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200075350AMedicaid
2072692OtherPK
2072692OtherPK