Provider Demographics
NPI:1396208757
Name:REVAN INC
Entity type:Organization
Organization Name:REVAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-773-8267
Mailing Address - Street 1:5601 NW 72ND ST STE 242
Mailing Address - Street 2:
Mailing Address - City:WARR ACRES
Mailing Address - State:OK
Mailing Address - Zip Code:73132-5923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 NW 72ND ST STE 142
Practice Address - Street 2:
Practice Address - City:WARR ACRES
Practice Address - State:OK
Practice Address - Zip Code:73132-5924
Practice Address - Country:US
Practice Address - Phone:888-773-8267
Practice Address - Fax:888-998-8267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-11
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200841490AMedicaid