Provider Demographics
NPI:1790833564
Name:CHOCTAW NATION OF OKLAHOMA
Entity type:Organization
Organization Name:CHOCTAW NATION OF OKLAHOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:K
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-567-7000
Mailing Address - Street 1:902 E LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:IDABEL
Mailing Address - State:OK
Mailing Address - Zip Code:74745-7337
Mailing Address - Country:US
Mailing Address - Phone:918-567-7096
Mailing Address - Fax:918-567-7041
Practice Address - Street 1:902 E LINCOLN RD
Practice Address - Street 2:
Practice Address - City:IDABEL
Practice Address - State:OK
Practice Address - Zip Code:74745-7337
Practice Address - Country:US
Practice Address - Phone:918-567-7096
Practice Address - Fax:918-567-7041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK255013261Q00000X, 332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
3724285OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100244980FMedicaid