Provider Demographics
NPI:1356915144
Name:ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC.
Entity type:Organization
Organization Name:ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MAL, FACHE, CMPE, CH
Authorized Official - Phone:405-447-0300
Mailing Address - Street 1:15951 LITTLE AXE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9088
Mailing Address - Country:US
Mailing Address - Phone:405-447-0300
Mailing Address - Fax:405-701-7631
Practice Address - Street 1:2029 GORDON COOPER DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-9005
Practice Address - Country:US
Practice Address - Phone:405-878-5850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-17
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy