1194185504 NPI number — GUARDIAN PHARMACY OF TULSA, LLC

Table of content: (NPI 1194185504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194185504 NPI number — GUARDIAN PHARMACY OF TULSA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GUARDIAN PHARMACY OF TULSA, LLC
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:
1194185504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11407
Provider Second Line Business Mailing Address:
DEPT # 2610
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35246-2610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-810-0089
Provider Business Mailing Address Fax Number:
404-810-0094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5415 S 125TH EAST AVE
Provider Second Line Business Practice Location Address:
SUITE 201-203
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74146-6232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-237-8217
Provider Business Practice Location Address Fax Number:
855-711-3900
Provider Enumeration Date:
02/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BURGESS
Authorized Official First Name:
RICKY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
866-237-8217

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  2-7811 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200611770C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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