Provider Demographics
NPI:1316196546
Name:EAST CENTRAL OKLAHOMA FAMILY HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:EAST CENTRAL OKLAHOMA FAMILY HEALTH CENTER, INC.
Other - Org Name:EAST CENTRAL OKLAHOMA FAMILY HEALTH CENTER, INC. PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-452-3151
Mailing Address - Street 1:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:WETUMKA
Mailing Address - State:OK
Mailing Address - Zip Code:74883-0236
Mailing Address - Country:US
Mailing Address - Phone:405-452-5400
Mailing Address - Fax:405-452-3000
Practice Address - Street 1:109 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WETUMKA
Practice Address - State:OK
Practice Address - Zip Code:74883-4015
Practice Address - Country:US
Practice Address - Phone:405-452-5400
Practice Address - Fax:405-452-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QF0400X, 333600000X
OK40-59413336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200235450AMedicaid
2134967OtherPK