Provider Demographics
NPI:1942215561
Name:LAKE COUNTRY HEALTHCARE LLC
Entity Type:Organization
Organization Name:LAKE COUNTRY HEALTHCARE LLC
Other - Org Name:LAKE COUNTRY HEALTHCARE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARSENA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-457-5535
Mailing Address - Street 1:27753 S WELLING RD
Mailing Address - Street 2:
Mailing Address - City:WELLING
Mailing Address - State:OK
Mailing Address - Zip Code:74471-2202
Mailing Address - Country:US
Mailing Address - Phone:918-457-9997
Mailing Address - Fax:918-457-5096
Practice Address - Street 1:27753 S WELLING RD
Practice Address - Street 2:
Practice Address - City:WELLING
Practice Address - State:OK
Practice Address - Zip Code:74471-2202
Practice Address - Country:US
Practice Address - Phone:918-457-9997
Practice Address - Fax:918-457-5096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2011-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK3655913336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3723625OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK200008180AMedicaid