Provider Demographics
NPI:1326198219
Name:WATONGA IHS PHARMACY
Entity Type:Organization
Organization Name:WATONGA IHS PHARMACY
Other - Org Name:WATONGA IHS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AREA PHARMACY CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-951-6035
Mailing Address - Street 1:PO BOX 676744
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RT 1
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772
Practice Address - Country:US
Practice Address - Phone:580-623-4991
Practice Address - Fax:580-623-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK49-2937332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100231960GMedicaid
2076413OtherPK