Provider Demographics
NPI:1093362337
Name:FOSTER CORNER DRUG LONG TERM CARE
Entity type:Organization
Organization Name:FOSTER CORNER DRUG LONG TERM CARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-372-4882
Mailing Address - Street 1:328 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:OK
Mailing Address - Zip Code:73077-6607
Mailing Address - Country:US
Mailing Address - Phone:580-336-2136
Mailing Address - Fax:580-336-9445
Practice Address - Street 1:328 N 6TH ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-6607
Practice Address - Country:US
Practice Address - Phone:580-336-2136
Practice Address - Fax:580-336-9445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-21
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232570AMedicaid