Provider Demographics
NPI:1225518079
Name:PROVIDENCE RX INC
Entity Type:Organization
Organization Name:PROVIDENCE RX INC
Other - Org Name:PROVIDENCE RX PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:AILEEN
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:918-808-6228
Mailing Address - Street 1:7302 S YALE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7032
Mailing Address - Country:US
Mailing Address - Phone:918-808-6228
Mailing Address - Fax:918-392-2950
Practice Address - Street 1:7302 S YALE AVE STE 101
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7032
Practice Address - Country:US
Practice Address - Phone:918-392-3366
Practice Address - Fax:918-392-2950
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No291U00000XLaboratoriesClinical Medical Laboratory
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200785950AMedicaid