Provider Demographics
NPI:1477876159
Name:BOOMER SOLUTIONS LLC
Entity Type:Organization
Organization Name:BOOMER SOLUTIONS LLC
Other - Org Name:BOOMER SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:877-774-3706
Mailing Address - Street 1:310 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:EUFAULA
Mailing Address - State:OK
Mailing Address - Zip Code:74432-3202
Mailing Address - Country:US
Mailing Address - Phone:877-774-3706
Mailing Address - Fax:888-852-2946
Practice Address - Street 1:310 S 1ST ST
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-3202
Practice Address - Country:US
Practice Address - Phone:877-774-3706
Practice Address - Fax:888-852-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK48-68283336L0003X
3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2124945OtherPK
OK200286150AMedicaid