Provider Demographics
NPI:1134205685
Name:JIMARDE INC
Entity type:Organization
Organization Name:JIMARDE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HUFF
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:405-605-0346
Mailing Address - Street 1:908 STRAKA TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73139-2534
Mailing Address - Country:US
Mailing Address - Phone:405-605-0346
Mailing Address - Fax:405-605-0348
Practice Address - Street 1:908 STRAKA TER
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139-2534
Practice Address - Country:US
Practice Address - Phone:405-605-0346
Practice Address - Fax:405-605-0348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0004X
OK1-45103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100246740AMedicaid
2076404OtherPK