Provider Demographics
NPI:1114917747
Name:PROSOURCE MEDICAL EQUIPMENT AND SUPPLIES
Entity Type:Organization
Organization Name:PROSOURCE MEDICAL EQUIPMENT AND SUPPLIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-691-3237
Mailing Address - Street 1:6801 S EASTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149-2300
Mailing Address - Country:US
Mailing Address - Phone:888-691-3237
Mailing Address - Fax:405-691-3395
Practice Address - Street 1:6801 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149-2300
Practice Address - Country:US
Practice Address - Phone:888-691-3237
Practice Address - Fax:405-691-3395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK117978332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100811900AMedicaid
OK100811900AMedicaid