Provider Demographics
NPI:1396860003
Name:CHICKASAW NATION DIVISION OF HEALTH
Entity Type:Organization
Organization Name:CHICKASAW NATION DIVISION OF HEALTH
Other - Org Name:PURCELL INDIAN HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:ZACH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-436-3980
Mailing Address - Street 1:1921 STONECIPHER DR
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3439
Mailing Address - Country:US
Mailing Address - Phone:580-421-4597
Mailing Address - Fax:580-421-4598
Practice Address - Street 1:1438 HARDCASTLE BLVD
Practice Address - Street 2:
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-8233
Practice Address - Country:US
Practice Address - Phone:580-272-5710
Practice Address - Fax:580-272-5711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK474906332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2076971OtherPK
OK100689860CMedicaid