Basic Information
| Provider Information | |||||||||
| NPI: | 1538299268 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUOYAH CITY COUNTY TRUST AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SEQUOYAH MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 E REDWOOD AVE | ||||||||
| Address2: | PO BOX 505 | ||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749552811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187741100 | ||||||||
| FaxNumber: | 9187741143 | ||||||||
| Practice Location | |||||||||
| Address1: | 213 E REDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749552811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187741100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WADE | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9187741100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 344802 | OK | Y | Suppliers | Non-Pharmacy Dispensing Site |
ID Information
| ID | Type | State | Issuer | Description | 344802 | 01 | OK | INPATIENT PHARMACY | OTHER |