Provider Demographics
NPI:1154733293
Name:ONESOURCE LLC
Entity type:Organization
Organization Name:ONESOURCE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TONY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDGINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-279-6001
Mailing Address - Street 1:31 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:CALERA
Mailing Address - State:OK
Mailing Address - Zip Code:74730-5519
Mailing Address - Country:US
Mailing Address - Phone:580-302-2322
Mailing Address - Fax:580-434-6250
Practice Address - Street 1:124 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:CADDO
Practice Address - State:OK
Practice Address - Zip Code:74729-2606
Practice Address - Country:US
Practice Address - Phone:580-279-6001
Practice Address - Fax:580-367-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-23
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27-67313336C0003X, 3336C0003X, 3336C0003X
3336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200447310BMedicaid
2145875OtherPK