Provider Demographics
NPI:1952323958
Name:PRAIRIE BAND POTAWATOMI NATION
Entity Type:Organization
Organization Name:PRAIRIE BAND POTAWATOMI NATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHARMACIST
Authorized Official - Prefix:
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:785-966-8266
Mailing Address - Street 1:11400 158TH RD
Mailing Address - Street 2:
Mailing Address - City:MAYETTA
Mailing Address - State:KS
Mailing Address - Zip Code:66509-0249
Mailing Address - Country:US
Mailing Address - Phone:785-966-8200
Mailing Address - Fax:785-966-8396
Practice Address - Street 1:11400 158TH RD
Practice Address - Street 2:
Practice Address - City:MAYETTA
Practice Address - State:KS
Practice Address - Zip Code:66509-8866
Practice Address - Country:US
Practice Address - Phone:866-727-6330
Practice Address - Fax:785-966-8396
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRAIRIE BAND POTAWATOMI NATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-25
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2-2546332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2027266OtherPK
KS200259300BMedicaid