Healthcare Provider Details

I. General information

NPI: 1336786896
Provider Name (Legal Business Name): PRESTIGE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2019
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 N BRYANT AVE, STE 110
EDMOND OK
73034-3255
US

IV. Provider business mailing address

1109 N BRYANT AVE, STE 110
EDMOND OK
73034-3255
US

V. Phone/Fax

Practice location:
  • Phone: 405-458-1777
  • Fax: 405-458-1777
Mailing address:
  • Phone: 405-458-1777
  • Fax: 405-458-1777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: ALAN JACKSON
Title or Position: OWNER/CEO
Credential:
Phone: 405-724-6630