Provider Demographics
NPI:1790939494
Name:HALO RX LLC
Entity Type:Organization
Organization Name:HALO RX LLC
Other - Org Name:HALO RX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-421-9885
Mailing Address - Street 1:703 N BROADWAY AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3457
Mailing Address - Country:US
Mailing Address - Phone:580-421-9885
Mailing Address - Fax:580-421-9732
Practice Address - Street 1:703 N BROADWAY AVE
Practice Address - Street 2:STE 3
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3457
Practice Address - Country:US
Practice Address - Phone:580-421-9885
Practice Address - Fax:580-421-9732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2353283336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2117706OtherPK