Provider Demographics
NPI:1336369404
Name:JIREH MEDICAL, LLC
Entity Type:Organization
Organization Name:JIREH MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:RACKLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-827-7600
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MOUNDS
Mailing Address - State:OK
Mailing Address - Zip Code:74047-0308
Mailing Address - Country:US
Mailing Address - Phone:918-827-7600
Mailing Address - Fax:918-827-7667
Practice Address - Street 1:1312 COMMERCIAL AVE
Practice Address - Street 2:
Practice Address - City:MOUNDS
Practice Address - State:OK
Practice Address - Zip Code:74047-0000
Practice Address - Country:US
Practice Address - Phone:918-827-7600
Practice Address - Fax:918-827-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 332BN1400X, 332BP3500X
OK11-6330332BX2000X, 333600000X, 3336C0003X, 3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy