Basic Information
| Provider Information | |||||||||
| NPI: | 1750406757 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHICKASAW NATION DIVISION OF HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | TISHOMINGO INDIAN CLINIC PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1921 STONECIPHER DR | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748203439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804214597 | ||||||||
| FaxNumber: | 5804214598 | ||||||||
| Practice Location | |||||||||
| Address1: | 817 E 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TISHOMINGO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734601800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803712392 | ||||||||
| FaxNumber: | 5804214552 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2007 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | ZACH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHARMACIST | ||||||||
| AuthorizedOfficialTelephone: | 5802722710 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPH | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 333600000X | N | Suppliers | Pharmacy | 3336C0003X | N | Suppliers | Pharmacy | Community/Retail Pharmacy | 332800000X | 61-6174 | OK | Y | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100244600B | 05 | OK | MEDICAID | 2074771 | 01 | PK | OTHER |