Healthcare Provider Details

I. General information

NPI: 1477876159
Provider Name (Legal Business Name): BOOMER SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 12/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S 1ST ST
EUFAULA OK
74432-3202
US

IV. Provider business mailing address

310 S 1ST ST
EUFAULA OK
74432-3202
US

V. Phone/Fax

Practice location:
  • Phone: 877-774-3706
  • Fax: 888-852-2946
Mailing address:
  • Phone: 877-774-3706
  • Fax: 888-852-2946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number48-6828
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: KYLE SIMMONS
Title or Position: PHARMACY MANAGER
Credential: PHARM D.
Phone: 877-774-3706