Provider Demographics
NPI:1912016148
Name:SAPULPA DRIVE IN PHARMACY
Entity Type:Organization
Organization Name:SAPULPA DRIVE IN PHARMACY
Other - Org Name:SAPULPA DRIVE IN PHARMACY INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:D PH
Authorized Official - Phone:918-224-6558
Mailing Address - Street 1:1029 E CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4516
Mailing Address - Country:US
Mailing Address - Phone:918-224-6558
Mailing Address - Fax:918-227-0595
Practice Address - Street 1:1029 E CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4516
Practice Address - Country:US
Practice Address - Phone:918-224-6558
Practice Address - Fax:918-227-0595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK11-10843336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100234640AMedicaid
OK90003909892Medicaid
2072609OtherPK
0377300001Medicare NSC