Provider Demographics
NPI:1952471039
Name:THE CITY DRUG, INC.
Entity Type:Organization
Organization Name:THE CITY DRUG, INC.
Other - Org Name:CITY DRUG, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WYATT
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:LIVELY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-273-3825
Mailing Address - Street 1:128 E CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NOWATA
Mailing Address - State:OK
Mailing Address - Zip Code:74048-2702
Mailing Address - Country:US
Mailing Address - Phone:918-273-3825
Mailing Address - Fax:918-273-2251
Practice Address - Street 1:128 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:NOWATA
Practice Address - State:OK
Practice Address - Zip Code:74048-2702
Practice Address - Country:US
Practice Address - Phone:918-273-3825
Practice Address - Fax:918-273-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK53-1233336C0003X, 3336C0003X
OK531233336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232330AMedicaid
2073027OtherPK
OK9000390124Medicaid