Provider Demographics
NPI:1689680670
Name:CITIZEN POTAWATOMI NATION
Entity Type:Organization
Organization Name:CITIZEN POTAWATOMI NATION
Other - Org Name:CITIZEN POTAWATOMI NATION CLINIC PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY COORDINATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:LAREAU
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:405-273-5236
Mailing Address - Street 1:2307 S GORDON COOPER DR
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-9007
Mailing Address - Country:US
Mailing Address - Phone:405-273-5236
Mailing Address - Fax:405-273-2392
Practice Address - Street 1:2307 S GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9007
Practice Address - Country:US
Practice Address - Phone:405-273-5236
Practice Address - Fax:405-273-2392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10-4078261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center