Basic Information
| Provider Information | |||||||||
| NPI: | 1639290778 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KLAMATH TRIBAL HEALTH & FAMILY SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KLAMATH TRIBAL HEALTH 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 S CHILOQUIN BLVD | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976246747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417832438 | ||||||||
| FaxNumber: | 5417833554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LANGFORD | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5417833551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PHARM D, BCPS, CDE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 332800000X | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 115761 | 05 | OR | MEDICAID | 2078297 | 01 | PK | OTHER |