1104851989 NPI number — CHEYENNE PROFESSIONAL DRUG, INC

Table of content: (NPI 1104851989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104851989 NPI number — CHEYENNE PROFESSIONAL DRUG, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHEYENNE PROFESSIONAL DRUG, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104851989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 111
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAYRE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73662-0111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-928-3633
Provider Business Mailing Address Fax Number:
580-928-3635

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1002 NE HIGHWAY 66 STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAYRE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73662-9312
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-928-3633
Provider Business Practice Location Address Fax Number:
580-928-3635
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAKEY
Authorized Official First Name:
EDDIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
580-374-1615

Provider Taxonomy Codes

  • Taxonomy code: 3336C0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336L0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2073595 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100244920A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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