Basic Information
| Provider Information | |||||||||
| NPI: | 1356915144 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC. | ||||||||
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| OtherOrganizationName: | ABSENTEE SHAWNEE PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15951 LITTLE AXE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017631 | ||||||||
| Practice Location | |||||||||
| Address1: | 2029 GORDON COOPER DR | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748019005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058785850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2021 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4054470300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MAL, FACHE, CMPE, CH | ||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
No ID Information.