Healthcare Provider Details

I. General information

NPI: 1083021125
Provider Name (Legal Business Name): JOE MANSOUR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11805 OLDWICK CIR
OKLAHOMA CITY OK
73162-3225
US

IV. Provider business mailing address

11805 OLDWICK CIR
OKLAHOMA CITY OK
73162-3225
US

V. Phone/Fax

Practice location:
  • Phone: 405-361-8080
  • Fax:
Mailing address:
  • Phone: 405-361-8080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number9876
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number23225
License Number StateTX

VIII. Authorized Official

Name: DR. JOE MANSOUR
Title or Position: STAFF PHARMACIST
Credential: D.PH.
Phone: 405-361-8080