Basic Information
Provider Information | |||||||||
NPI: | 1699790543 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | AST LITTLE AXE HEALTH CENTER PHARMACY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15951 LITTLE AXE DRIVE | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730269001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4054470300 | ||||||||
FaxNumber: | 4057017631 | ||||||||
Practice Location | |||||||||
Address1: | 15951 LITTLE AXE DRIVE | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730269001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052929530 | ||||||||
FaxNumber: | 4057017930 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 06/30/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROGERS | ||||||||
AuthorizedOfficialFirstName: | MARK | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4054470300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MAL, FACHE, CMPE,CHC | ||||||||
NPICertificationDate: | 06/30/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | 7-5950 | OK | Y |   | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 100699860B | 05 | OK |   | MEDICAID |