Healthcare Provider Details

I. General information

NPI: 1134205685
Provider Name (Legal Business Name): JIMARDE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

908 STRAKA TER
OKLAHOMA CITY OK
73139-2534
US

IV. Provider business mailing address

908 STRAKA TER
OKLAHOMA CITY OK
73139-2534
US

V. Phone/Fax

Practice location:
  • Phone: 405-605-0346
  • Fax: 405-605-0348
Mailing address:
  • Phone: 405-605-0346
  • Fax: 405-605-0348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number1-4510
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JIM HUFF
Title or Position: OWNER
Credential: RPH
Phone: 405-605-0346