Active NPI
Providentia LLC
- Community/Retail Pharmacy
- Tulsa, OK
National Provider Identifier
1295101632
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Community/Retail Pharmacy
- License
- PD07681
- Legal business name
- PROVIDENTIA LLC
- Practice address
- 4227 Southwest Blvd
Crystal City Shopping Center
Tulsa, OK 74107-6522 - Phone
- (918) 986-8644
- Fax
- (918) 986-8655
- NPI assigned
- Aug 20, 2015
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Andrew Aaron Kohler
- Title
- Principal
- Phone
- (918) 743-4491
Specialties & licenses 4
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Durable Medical Equipment & Medical Supplies | 332B00000X | 2-7324 | OK | |
| Pharmacy | 333600000X | |||
| Community/Retail Pharmacy | 3336C0003X | PD07681 | AR | Primary |
| Long Term Care Pharmacy | 3336L0003X |
Addresses
Primary practice location
4227 Southwest Blvd
Crystal City Shopping Center
Tulsa, OK 74107-6522
Mailing address
4112 S Peoria Ave
Tulsa, OK 74105-7613
Phone (918) 743-4491
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 100232760 F | Medicaid | OK | |
| 2153603 | Other | PK |
Other names 1
- FREELAND BROWN PHARMACY NO. 3
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in OK
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20120920000234 | OK | Part B Supplier - Mass Immunization (Roster Biller Only) | 8123298833 |
2 other NPIs on this enrollment This NPI is an additional NPI on the enrollment Practice locations: Tulsa, OK |
Other NPIs on the same Medicare enrollment 2
NPIs listed together on one Medicare enrollment, typically parts of the same organization.
National Provider Directory
National Provider Directory- Tax ID family
- Freeland Brown Pharmacy
Other organizations with this tax ID 1
Organizations that report the same tax identification number in the National Provider Directory.
-
- Community/Retail Pharmacy
- Tulsa, OK
- NPI 1710910237
Member organizations 5
Organizations listed as members of this organization in the National Provider Directory.
Locations
4227 Southwest Blvd
Tulsa, OK 74107
Phone (918) 280-1870
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1440028800000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1595894400000",
"number": "1295101632",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4112 S PEORIA AVE",
"city": "TULSA",
"state": "OK",
"postal_code": "741057613",
"telephone_number": "918-743-4491",
"fax_number": "918-743-5432"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4227 SOUTHWEST BLVD",
"address_2": "CRYSTAL CITY SHOPPING CENTER",
"city": "TULSA",
"state": "OK",
"postal_code": "741076522",
"telephone_number": "918-986-8644",
"fax_number": "918-986-8655"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "PROVIDENTIA LLC",
"organizational_subpart": "NO",
"enumeration_date": "2015-08-20",
"last_updated": "2020-07-28",
"certification_date": "2020-07-28",
"status": "A",
"authorized_official_last_name": "KOHLER",
"authorized_official_first_name": "ANDREW",
"authorized_official_middle_name": "AARON",
"authorized_official_title_or_position": "PRINCIPAL",
"authorized_official_telephone_number": "918-743-4491"
},
"taxonomies": [
{
"code": "332B00000X",
"taxonomy_group": "",
"desc": "Durable Medical Equipment & Medical Supplies",
"state": "OK",
"license": "2-7324",
"primary": false
},
{
"code": "333600000X",
"taxonomy_group": "",
"desc": "Pharmacy",
"state": null,
"license": null,
"primary": false
},
{
"code": "3336C0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Community/Retail Pharmacy",
"state": "AR",
"license": "PD07681",
"primary": true
},
{
"code": "3336L0003X",
"taxonomy_group": "",
"desc": "Pharmacy, Long Term Care Pharmacy",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "100232760 F",
"state": "OK"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PK",
"identifier": "2153603",
"state": null
}
],
"endpoints": [],
"other_names": [
{
"organization_name": "FREELAND BROWN PHARMACY NO. 3",
"code": "3",
"type": "Doing Business As"
},
{
"organization_name": "FREELAND BROWN PHARMACY NO. 3",
"code": "3",
"type": "Doing Business As"
}
]
}Other providers in Tulsa, OK
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 28, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.