Providentia LLC

Primary specialty

Community/Retail PharmacyTaxonomy code 3336C0003X

License

2-5706 Issued in OK

Legal business name

PROVIDENTIA LLC

Practice address

4112 S Peoria Ave
Tulsa, OK 74105-7613

Phone

(918) 743-4491

Fax

(918) 743-5432

NPI assigned

Jul 8, 2006

Organization subpart

No

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

Authorized official

Name

Andrew Aaron Kohler

Title

Owner/Manager

Phone

(918) 743-4491

Specialties & licenses 4

Addresses

Other identifiers 3

Other names 1

• Freeland Brown Pharmacy Doing business as

Medicare fee-for-service enrollment

Enrolled in OK2 enrollments

Enrollment records 2

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 1700965472

  O20120920000234

  Same enrollment

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Medicare medical equipment & supply locations

Tax ID family

Freeland Brown Pharmacy2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

• Providentia LLC

  • Community/Retail Pharmacy
  • Tulsa, OK
  • NPI 1295101632
  NPD tax ID

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

{
    "created_epoch": "1152316800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1595894400000",
    "number": "1710910237",
    "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": "4112 S PEORIA AVE",
            "city": "TULSA",
            "state": "OK",
            "postal_code": "741057613",
            "telephone_number": "918-743-4491",
            "fax_number": "918-743-5432"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVIDENTIA LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-07-08",
        "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": "OWNER/MANAGER",
        "authorized_official_telephone_number": "918-743-4491"
    },
    "taxonomies": [
        {
            "code": "332B00000X",
            "taxonomy_group": "",
            "desc": "Durable Medical Equipment & Medical Supplies",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "3336C0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Community/Retail Pharmacy",
            "state": "OK",
            "license": "2-5706",
            "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 B",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100232760 A",
            "state": "OK"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2130880",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Freeland Brown Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Freeland Brown Pharmacy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Providence MRI Associates
• Providence Radiology
• Providence RX Inc
• Providentia LLC
• Providentia LLC
• Derrick Wayne Pruitt, MEDICAL STUDENT
• Joseph Edward Pruitt, PA-C
• Kristin Mariah Pruitt, APRN-CNS
• Jean Michelle Pryor, OT
• PS&a Case Management & Provider Agency

• 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 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.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.