Providentia LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2-6651 Issued in OK

Legal business name

PROVIDENTIA LLC

Practice address

1507 W 51St St
Tulsa, OK 74107-8041

Phone

(918) 446-1404

Fax

(918) 794-1610

NPI assigned

Nov 3, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Michael Dotson, BS PHARMACY

Title

Owner

Phone

(918) 688-9149

Specialties & licenses 3

Addresses

Other identifiers 2

Other names 1

• Freeland Brown Pharmacy No. 2 Doing business as

Medicare fee-for-service enrollment

Enrolled in OK

Enrollment records 1

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

• Providentia LLC

  • Community/Retail Pharmacy
  • Tulsa, OK
  • NPI 1295101632

  O20120920000234

  Same enrollment
• Providentia LLC

  • Community/Retail Pharmacy
  • Tulsa, OK
  • NPI 1710910237

  O20120920000234

  Same enrollment

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Bobby Alfred Sturgeon Jr., DPH

  • Pharmacist
  • Tulsa, OK
  • NPI 1659323517
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1162512000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1478563200000",
    "number": "1700965472",
    "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": "1507 W 51ST ST",
            "city": "TULSA",
            "state": "OK",
            "postal_code": "741078041",
            "telephone_number": "918-446-1404",
            "fax_number": "918-794-1610"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENTIA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-11-03",
        "last_updated": "2016-11-08",
        "status": "A",
        "authorized_official_last_name": "DOTSON",
        "authorized_official_first_name": "MICHAEL",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "918-688-9149",
        "authorized_official_credential": "BS PHARMACY"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OK",
            "license": "2-6651",
            "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": "100235670G",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2144892",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Freeland Brown Pharmacy No. 2",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

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• Providentia LLC
• Providentia LLC
• Derrick Wayne Pruitt, MEDICAL STUDENT
• Joseph Edward Pruitt, PA-C
• Kristin Mariah Pruitt, APRN-CNS
• Jean Michelle Pryor, OT

• Community/Retail Pharmacy in Tulsa, OK
• Providers in Tulsa, OK by specialty
• Community/Retail Pharmacy in Oklahoma

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2016; 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.

Verify at the official NPI Registry.