Provider Demographics
NPI:1588733869
Name:BOULEVARD PHARMACY INC
Entity type:Organization
Organization Name:BOULEVARD PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:
Authorized Official - Last Name:DESHAZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-336-2388
Mailing Address - Street 1:1117 SE FRANK PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74003-4319
Mailing Address - Country:US
Mailing Address - Phone:918-336-2388
Mailing Address - Fax:918-336-0016
Practice Address - Street 1:1117 SE FRANK PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74003-4319
Practice Address - Country:US
Practice Address - Phone:918-336-2388
Practice Address - Fax:918-336-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232160BMedicaid
OK100232160BMedicaid
OK0387160001Medicare NSC