Healthcare Provider Details

I. General information

NPI: 1285718320
Provider Name (Legal Business Name): MED-X CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 11/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1339 E 41ST ST
TULSA OK
74105-4031
US

IV. Provider business mailing address

2100 BROOKWOOD DR
LITTLE ROCK AR
72202-1734
US

V. Phone/Fax

Practice location:
  • Phone: 918-744-5490
  • Fax: 918-743-1051
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number22630
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number22630
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. GARY M. BOONE
Title or Position: DIRECTOR OF HME OPERATIONS
Credential:
Phone: 479-394-6363