Basic Information
| Provider Information | |||||||||
| NPI: | 1811980154 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OKLAHOMA CITY INDIAN CLINIC PHARMACY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4913 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | 4059484929 | ||||||||
| Practice Location | |||||||||
| Address1: | 4913 W RENO AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731276339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059484900 | ||||||||
| FaxNumber: | 4059484929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SUNDAY-ALLEN | ||||||||
| AuthorizedOfficialFirstName: | ROBYN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4059484900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTRAL OKLAHOMA AMERICAN INDIAN HEALTH COUNCIL, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, MPH | ||||||||
| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332800000X | N | Suppliers | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy | 333600000X | 14183 | OK | Y | Suppliers | Pharmacy |
ID Information
| ID | Type | State | Issuer | Description | 100243180A | 05 | OK | MEDICAID |