Provider Demographics
NPI:1083021125
Name:JOE MANSOUR
Entity Type:Organization
Organization Name:JOE MANSOUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-361-8080
Mailing Address - Street 1:11805 OLDWICK CIR
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73162-3225
Mailing Address - Country:US
Mailing Address - Phone:405-361-8080
Mailing Address - Fax:
Practice Address - Street 1:11805 OLDWICK CIR
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73162-3225
Practice Address - Country:US
Practice Address - Phone:405-361-8080
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9876261QM1300X
TX23225261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine