Provider Demographics
NPI:1598181000
Name:THERACOMPRX LLC
Entity type:Organization
Organization Name:THERACOMPRX LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST-IN-CHARGE/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:BAILES
Authorized Official - Suffix:II
Authorized Official - Credentials:RPH, PHARMD
Authorized Official - Phone:580-759-6238
Mailing Address - Street 1:1414 ARLINGTON ST
Mailing Address - Street 2:STE 2200
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2646
Mailing Address - Country:US
Mailing Address - Phone:580-436-9922
Mailing Address - Fax:580-436-9919
Practice Address - Street 1:1414 ARLINGTON ST
Practice Address - Street 2:STE 2200
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2646
Practice Address - Country:US
Practice Address - Phone:580-436-9922
Practice Address - Fax:580-436-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23-66203336C0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0004XSuppliersPharmacyCompounding Pharmacy