Provider Demographics
NPI:1033462593
Name:WYANDOTTE NATION
Entity Type:Organization
Organization Name:WYANDOTTE NATION
Other - Org Name:BEARSKIN HEALTH CLINIC PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:SWEATT
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:918-678-3247
Mailing Address - Street 1:1 TURTLE DR
Mailing Address - Street 2:
Mailing Address - City:WYANDOTTE
Mailing Address - State:OK
Mailing Address - Zip Code:74370-2114
Mailing Address - Country:US
Mailing Address - Phone:918-678-2282
Mailing Address - Fax:918-678-3136
Practice Address - Street 1:1 TURTLE DR
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:OK
Practice Address - Zip Code:74370-2114
Practice Address - Country:US
Practice Address - Phone:918-678-3247
Practice Address - Fax:918-678-3136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK21-60443336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2137552OtherPK
OK100707880GMedicaid