Provider Demographics
NPI:1558871228
Name:COQUILLE INDIAN TRIBE
Entity Type:Organization
Organization Name:COQUILLE INDIAN TRIBE
Other - Org Name:CIT RETAIL PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH AND HUMAN SERVICES ADMINISTR
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-888-9494
Mailing Address - Street 1:PO BOX 3190
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420
Mailing Address - Country:US
Mailing Address - Phone:541-888-9494
Mailing Address - Fax:
Practice Address - Street 1:630 MILUK DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-7728
Practice Address - Country:US
Practice Address - Phone:541-435-7039
Practice Address - Fax:541-982-5352
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COQUILLE INDIAN TRIBE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-06
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRP-0003304333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy