Provider Demographics
NPI:1669610259
Name:PIEDMONT RX INC
Entity type:Organization
Organization Name:PIEDMONT RX INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-373-3090
Mailing Address - Street 1:97 GOODER SIMPSON BLVD
Mailing Address - Street 2:
Mailing Address - City:PIEDMONT
Mailing Address - State:OK
Mailing Address - Zip Code:73078-9215
Mailing Address - Country:US
Mailing Address - Phone:405-373-3090
Mailing Address - Fax:405-373-1748
Practice Address - Street 1:97 GOODER SIMPSON BLVD
Practice Address - Street 2:
Practice Address - City:PIEDMONT
Practice Address - State:OK
Practice Address - Zip Code:73078-9215
Practice Address - Country:US
Practice Address - Phone:405-373-3090
Practice Address - Fax:405-373-1748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X, 333600000X, 3336C0004X, 3336L0003X
OK26-81423336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200230700AMedicaid
2118895OtherPK
OK200230700AMedicaid