Provider Demographics
NPI:1962911123
Name:OKLAHOMA ADVANTAGE STOREHOUSE, LLC
Entity type:Organization
Organization Name:OKLAHOMA ADVANTAGE STOREHOUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:MADISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-306-1549
Mailing Address - Street 1:109 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:OK
Mailing Address - Zip Code:74637-1533
Mailing Address - Country:US
Mailing Address - Phone:918-642-5492
Mailing Address - Fax:918-601-2740
Practice Address - Street 1:109 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:OK
Practice Address - Zip Code:74637-1533
Practice Address - Country:US
Practice Address - Phone:918-642-5492
Practice Address - Fax:918-601-2740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies