Healthcare Provider Details

I. General information

NPI: 1790939494
Provider Name (Legal Business Name): HALO RX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N BROADWAY AVE STE 3
ADA OK
74820-3457
US

IV. Provider business mailing address

703 N BROADWAY AVE STE 3
ADA OK
74820-3457
US

V. Phone/Fax

Practice location:
  • Phone: 580-421-9885
  • Fax: 580-421-9732
Mailing address:
  • Phone: 580-421-9885
  • Fax: 580-421-9732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number235328
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier2117706
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: KENNETH BAILES
Title or Position: PHARMACIST IN CHARGE
Credential:
Phone: 580-421-9885