Basic Information
Provider Information | |||||||||
NPI: | 1801925060 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SISSETON WAHPETON OYATE HEALTHCARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WOODROW WILSON KEEBLE MEMORIAL HEALTH CARE CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3124 SOLUTIONS CTR | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606773001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 LAKE TRAVERSE DR | ||||||||
Address2: |   | ||||||||
City: | SISSETON | ||||||||
State: | SD | ||||||||
PostalCode: | 572627046 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6056987606 | ||||||||
FaxNumber: | 6056984270 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/05/2007 | ||||||||
LastUpdateDate: | 10/28/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CUMMINGS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHARMACY PROGRAM SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 4059516086 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHARMD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X |   |   | Y |   | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 2094248 | 01 |   | PK | OTHER | 5549030 | 05 | SD |   | MEDICAID |