Provider Demographics
NPI:1881616456
Name:IOWA TRIBE OF OKLAHOMA
Entity type:Organization
Organization Name:IOWA TRIBE OF OKLAHOMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:DAUGHERTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-547-2473
Mailing Address - Street 1:PO BOX 460
Mailing Address - Street 2:
Mailing Address - City:PERKINS
Mailing Address - State:OK
Mailing Address - Zip Code:74059-0460
Mailing Address - Country:US
Mailing Address - Phone:405-547-2473
Mailing Address - Fax:405-547-2925
Practice Address - Street 1:509 E HIGHWAY 33
Practice Address - Street 2:
Practice Address - City:PERKINS
Practice Address - State:OK
Practice Address - Zip Code:74059-4129
Practice Address - Country:US
Practice Address - Phone:405-547-2473
Practice Address - Fax:405-547-2925
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2019-09-18
Deactivation Date:2008-08-12
Deactivation Code:
Reactivation Date:2008-08-28
Provider Licenses
StateLicense IDTaxonomies
333600000X
OK8-5151332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100707800BMedicaid
2077058OtherPK