Provider Demographics
NPI:1760778385
Name:PONCA TRIBE OF NEBRASKA
Entity Type:Organization
Organization Name:PONCA TRIBE OF NEBRASKA
Other - Org Name:FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:402-734-5275
Mailing Address - Street 1:2602 J ST
Mailing Address - Street 2:FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68107-1643
Mailing Address - Country:US
Mailing Address - Phone:402-734-5275
Mailing Address - Fax:402-733-3487
Practice Address - Street 1:2602 J ST
Practice Address - Street 2:FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-1643
Practice Address - Country:US
Practice Address - Phone:402-734-5275
Practice Address - Fax:402-733-3487
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PONCA TRIBE OF NEBRASKA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2884332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE2884OtherPHARMACY LICENSE NUMBER
2817964OtherNCPDP