Provider Demographics
NPI:1710249628
Name:THE CHICKASAW NATION EMPLOYEE CLINIC PHARMACY- ADA
Entity Type:Organization
Organization Name:THE CHICKASAW NATION EMPLOYEE CLINIC PHARMACY- ADA
Other - Org Name:CHICKASAW NATION EMPLOYEE CLINIC PHARMACY- NORMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF TRIBAL PHARMACY SERVICE
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:580-235-6419
Mailing Address - Street 1:1007 N COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2847
Mailing Address - Country:US
Mailing Address - Phone:580-421-8775
Mailing Address - Fax:580-421-8789
Practice Address - Street 1:1007 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2847
Practice Address - Country:US
Practice Address - Phone:580-421-8775
Practice Address - Fax:580-421-8789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-15
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK23-59663336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200436850AMedicaid
2135608OtherPK