Provider Demographics
NPI:1407901671
Name:TONI'S WESTSIDE REXALL INC
Entity Type:Organization
Organization Name:TONI'S WESTSIDE REXALL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:K
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
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:2007-01-25
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6-2133332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235620BMedicaid
OK0237820001Medicare NSC