Provider Demographics
NPI:1154416162
Name:GLN OF CHECOTAH INC
Entity type:Organization
Organization Name:GLN OF CHECOTAH INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:918-473-2304
Mailing Address - Street 1:207 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:CHECOTAH
Mailing Address - State:OK
Mailing Address - Zip Code:74426-2431
Mailing Address - Country:US
Mailing Address - Phone:918-473-2304
Mailing Address - Fax:918-473-6133
Practice Address - Street 1:207 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHECOTAH
Practice Address - State:OK
Practice Address - Zip Code:74426-2431
Practice Address - Country:US
Practice Address - Phone:918-473-2304
Practice Address - Fax:918-473-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
OK4839353336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100243600AMedicaid
4469790001Medicare NSC