Healthcare Provider Details

I. General information

NPI: 1336369404
Provider Name (Legal Business Name): JIREH MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2007
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 COMMERCIAL AVE
MOUNDS OK
74047-0000
US

IV. Provider business mailing address

PO BOX 308
MOUNDS OK
74047-0308
US

V. Phone/Fax

Practice location:
  • Phone: 918-827-7600
  • Fax: 918-827-7667
Mailing address:
  • Phone: 918-827-7600
  • Fax: 918-827-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number11-6330
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number11-6330
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number11-6330
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number11-6330
License Number StateOK
# 7
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. KYLE DEAN RACKLEY
Title or Position: PRESIDENT
Credential:
Phone: 918-827-7600