Basic Information
| Provider Information | |||||||||
| NPI: | 1588805832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KLAMATH TRIBAL HEALTH AND FAMILY SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KLAMATH TRIBAL PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976240490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417832438 | ||||||||
| FaxNumber: | 5417833554 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 CHILOQUIN BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97624 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417832438 | ||||||||
| FaxNumber: | 5417833554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2009 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | MARCUS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5417832438 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 2612F0400X | OR | N | Ambulatory Health Care Facilities | Clinic/Center | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 181550 | 05 | OR | MEDICAID |