Provider Demographics
NPI:1083084768
Name:GUARDIAN PHARMACY OF OKLAHOMA LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF OKLAHOMA LLC
Other - Org Name:BOOMER SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-774-3706
Mailing Address - Street 1:PO BOX 11407
Mailing Address - Street 2:DEPT # 2610
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-2610
Mailing Address - Country:US
Mailing Address - Phone:404-810-0089
Mailing Address - Fax:404-810-0094
Practice Address - Street 1:310 S 1ST ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3202
Practice Address - Country:US
Practice Address - Phone:877-774-3706
Practice Address - Fax:888-852-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-07
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X
OK4874293336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200611770AMedicaid
2154687OtherPK
2154687OtherPK
OK200611770AMedicaid
OK200611770AMedicaid