Provider Demographics
NPI:1477674075
Name:KAW NATION
Entity type:Organization
Organization Name:KAW NATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOANNA
Authorized Official - Middle Name:GAYLE
Authorized Official - Last Name:POTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-362-1039
Mailing Address - Street 1:PO BOX 474
Mailing Address - Street 2:3151 E RIVER RD
Mailing Address - City:NEWKIRK
Mailing Address - State:OK
Mailing Address - Zip Code:74647
Mailing Address - Country:US
Mailing Address - Phone:580-362-2449
Mailing Address - Fax:580-362-1405
Practice Address - Street 1:3151 E RIVER RD
Practice Address - Street 2:
Practice Address - City:NEWKIRK
Practice Address - State:OK
Practice Address - Zip Code:74647
Practice Address - Country:US
Practice Address - Phone:580-362-2449
Practice Address - Fax:580-362-1405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6-4338183500000X
3336C0003X, 332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100245620AMedicaid