Provider Demographics
NPI:1821154709
Name:SOONER DRUG AND GIFTS OR OKEMAH
Entity Type:Organization
Organization Name:SOONER DRUG AND GIFTS OR OKEMAH
Other - Org Name:SOONER DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-623-1036
Mailing Address - Street 1:324 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:OKEMAH
Mailing Address - State:OK
Mailing Address - Zip Code:74859-2608
Mailing Address - Country:US
Mailing Address - Phone:918-623-1771
Mailing Address - Fax:918-623-0238
Practice Address - Street 1:324 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:OKEMAH
Practice Address - State:OK
Practice Address - Zip Code:74859-2608
Practice Address - Country:US
Practice Address - Phone:918-623-1771
Practice Address - Fax:918-623-0238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2016-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5129483336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2073031OtherPK
OK100239620AMedicaid
0292620001Medicare NSC