=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801146782
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHYSICIAN PREFERRED MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2012
-----------------------------------------------------
Last Update Date | 09/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3300 NW 56TH ST 101
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-203-0681
-----------------------------------------------------
Fax | 405-213-1554
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3300 NW 56TH ST SUITE 101
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-4538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-203-0681
-----------------------------------------------------
Fax | 405-213-1554
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | KENNETH RYAN ORTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-206-1313
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0003X
-----------------------------------------------------
Taxonomy Name | Community/Retail Pharmacy
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------