Provider Demographics
NPI:1174088454
Name:PHARMACY @ WELLSTON
Entity type:Organization
Organization Name:PHARMACY @ WELLSTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TECHNICIAN/ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEETIN-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-356-4199
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OK
Mailing Address - Zip Code:74881-0056
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:309 W 2ND ST
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OK
Practice Address - Zip Code:74881-7488
Practice Address - Country:US
Practice Address - Phone:405-356-4199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK31-8331OtherPHARMACY LICENSE - OKLAHOMA STATE BOARD OF PHARMACY