Provider Demographics
NPI:1326294968
Name:CHEROKEE NATION OUTPATIENT HEALTH CENTER PHARMACY
Entity Type:Organization
Organization Name:CHEROKEE NATION OUTPATIENT HEALTH CENTER PHARMACY
Other - Org Name:CHEROKEE NATION OUTPATIENT HEALTH CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIR., HEALTH EDUCATION & STAFF DEV
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:539-234-1977
Mailing Address - Street 1:19600 E ROSS STREET
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:539-234-1100
Mailing Address - Fax:
Practice Address - Street 1:19600 E ROSS STREET
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:539-234-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK365339332800000X
332800000X, 333600000X, 3336C0002X, 3336S0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
No332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100239190AMedicaid
2117386OtherPK
OK100239180AMedicaid