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NPI Code Detail

MEDICARE: PROVIDENTIA LLC

MEDICARE: PROVIDENTIA LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1332B00000XDurable Medical Equipment & Medical Supplies
2333600000XPharmacy
33336L0003XLong Term Care Pharmacy
43336C0003XCommunity/Retail Pharmacy2-5706OK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
32130880OTHERPK

General Provider Information

NPI Number : 1710910237
Entity Type Code : Organization
Provider Name (Legal Business Name) : PROVIDENTIA LLC
Provider Business Mailing Address
First Line : 4112 S PEORIA AVE
Second Line :
City : TULSA
State : OK
Zip : 74105-7613
Country : US
Telephone Number : 918-743-4491
Fax Number : 918-743-5432
Provider Business Practice Location Address
First Line : 4112 S PEORIA AVE
Second Line :
City : TULSA
State : OK
Zip : 74105-7613
Country : US
Telephone Number : 918-743-4491
Fax Number : 918-743-5432
Authorized Official
Title or Position : OWNER/MANAGER
Name : ANDREW AARON KOHLER
Credential :
Telephone Number : 918-743-4491
Provider Enumeration Date : 07/08/2006
Last Update Date : 07/28/2020

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1750637195 — STEPHEN ROBERT STRONG D.PH.
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1821427428 — MATTHEW CORGILL
Practice Location Address:
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74105-7613
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Practice Fax: 918-743-5432

Directions to “PROVIDENTIA LLC ” Practice Location

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