Provider Demographics
NPI:1952303190
Name:PAWHUSKA IHS PHARMACY
Entity Type:Organization
Organization Name:PAWHUSKA IHS PHARMACY
Other - Org Name:PAWHUSKA IHS PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AREA PHARMACY CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:405-951-6035
Mailing Address - Street 1:PO BOX 676748
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-6748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:PAWHUSKA
Practice Address - State:OK
Practice Address - Zip Code:74056-3201
Practice Address - Country:US
Practice Address - Phone:918-287-4491
Practice Address - Fax:918-287-2347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK162939332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100231960FMedicaid
3717925OtherNCPDP PROVIDER IDENTIFICATION NUMBER