Healthcare Provider Details

I. General information

NPI: 1538266796
Provider Name (Legal Business Name): JINNY ANN 4 CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3252 SE 29TH ST
DEL CITY OK
73115-1601
US

IV. Provider business mailing address

PO BOX 15330
DEL CITY OK
73155-5330
US

V. Phone/Fax

Practice location:
  • Phone: 405-677-0549
  • Fax: 405-672-0369
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number13455
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JOHN LASSITER
Title or Position: PRESIDENT
Credential:
Phone: 405-677-0549