Provider Demographics
NPI:1013074111
Name:JACK JUSTICE
Entity Type:Organization
Organization Name:JACK JUSTICE
Other - Org Name:REAVIS REXALL DRUG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JUSTICE
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-238-7391
Mailing Address - Street 1:110 BURR AVE
Mailing Address - Street 2:
Mailing Address - City:PAULS VALLEY
Mailing Address - State:OK
Mailing Address - Zip Code:73075-3848
Mailing Address - Country:US
Mailing Address - Phone:405-238-7391
Mailing Address - Fax:405-238-1162
Practice Address - Street 1:110 BURR AVE
Practice Address - Street 2:
Practice Address - City:PAULS VALLEY
Practice Address - State:OK
Practice Address - Zip Code:73075-3848
Practice Address - Country:US
Practice Address - Phone:405-238-7391
Practice Address - Fax:405-238-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK223755332B00000X, 332BP3500X, 332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Not Answered332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Not Answered332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100235750BMedicaid