Provider Demographics
NPI:1992079438
Name:PRIME SOURCE DME OF OKLAHOMA
Entity type:Organization
Organization Name:PRIME SOURCE DME OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-935-2088
Mailing Address - Street 1:6810 E 40TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-4510
Mailing Address - Country:US
Mailing Address - Phone:918-935-2088
Mailing Address - Fax:918-935-2087
Practice Address - Street 1:6810 E 40TH ST STE A
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-4510
Practice Address - Country:US
Practice Address - Phone:918-935-2088
Practice Address - Fax:918-935-2087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies