Provider Demographics
NPI:1295101632
Name:PROVIDENTIA LLC
Entity type:Organization
Organization Name:PROVIDENTIA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:KOHLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-743-4491
Mailing Address - Street 1:4112 S PEORIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7613
Mailing Address - Country:US
Mailing Address - Phone:918-743-4491
Mailing Address - Fax:918-743-5432
Practice Address - Street 1:4227 SOUTHWEST BLVD
Practice Address - Street 2:CRYSTAL CITY SHOPPING CENTER
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74107-6522
Practice Address - Country:US
Practice Address - Phone:918-986-8644
Practice Address - Fax:918-986-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2-7324332B00000X
333600000X, 3336L0003X
ARPD076813336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No333600000XSuppliersPharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100232760 FMedicaid
2153603OtherPK