Healthcare Provider Details

I. General information

NPI: 1598181000
Provider Name (Legal Business Name): THERACOMPRX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2014
Last Update Date: 03/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 ARLINGTON ST STE 2200
ADA OK
74820-2646
US

IV. Provider business mailing address

1414 ARLINGTON ST STE 2200
ADA OK
74820-2646
US

V. Phone/Fax

Practice location:
  • Phone: 580-436-9922
  • Fax: 580-436-9919
Mailing address:
  • Phone: 580-436-9922
  • Fax: 580-436-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number23-6620
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. KENNETH WAYNE BAILES II
Title or Position: PHARMACIST-IN-CHARGE/OWNER
Credential: RPH, PHARMD
Phone: 580-759-6238