1194185504 NPI number — GUARDIAN PHARMACY OF TULSA, LLC

Table of Contents

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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