Provider Demographics
NPI:1194185504
Name:GUARDIAN PHARMACY OF TULSA, LLC
Entity Type:Organization
Organization Name:GUARDIAN PHARMACY OF TULSA, LLC
Other - Org Name:BOOMER SOLUTIONS OF TULSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-237-8217
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 1:5415 S 125TH EAST AVE
Practice Address - Street 2:SUITE 201-203
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6232
Practice Address - Country:US
Practice Address - Phone:866-237-8217
Practice Address - Fax:855-711-3900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2-78113336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200611770CMedicaid
OK200611770CMedicaid