Provider Demographics
NPI:1043029887
Name:PRIME MEDICAL OUTLET LLC
Entity type:Organization
Organization Name:PRIME MEDICAL OUTLET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZAVEEN
Authorized Official - Middle Name:KHAN
Authorized Official - Last Name:TATARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-708-2081
Mailing Address - Street 1:1005 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4733
Mailing Address - Country:US
Mailing Address - Phone:240-708-2081
Mailing Address - Fax:
Practice Address - Street 1:1005 S MUSKOGEE AVE
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4733
Practice Address - Country:US
Practice Address - Phone:240-708-2081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-06
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies