Provider Demographics
NPI:1164437901
Name:TONI'S WESTSIDE REXALL INC
Entity Type:Organization
Organization Name:TONI'S WESTSIDE REXALL INC
Other - Org Name:TONI'S WESTSIDE HEALTHMART
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHARMACISTS
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:K
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-765-4456
Mailing Address - Street 1:301 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-5118
Mailing Address - Country:US
Mailing Address - Phone:580-765-4456
Mailing Address - Fax:580-765-0668
Practice Address - Street 1:301 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5118
Practice Address - Country:US
Practice Address - Phone:580-765-4456
Practice Address - Fax:580-765-0668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
OK621333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235620AMedicaid
2073065OtherPK
OK100235620BMedicaid
OK100235620BMedicaid