Healthcare Provider Details

I. General information

NPI: 1760778385
Provider Name (Legal Business Name): PONCA TRIBE OF NEBRASKA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2011
Last Update Date: 06/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2602 J ST FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY
OMAHA NE
68107-1643
US

IV. Provider business mailing address

2602 J ST FRED LEROY HEALTH AND WELLNESS CENTER PHARMACY
OMAHA NE
68107-1643
US

V. Phone/Fax

Practice location:
  • Phone: 402-734-5275
  • Fax: 402-733-3487
Mailing address:
  • Phone: 402-734-5275
  • Fax: 402-733-3487

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number2884
License Number StateNE

VIII. Authorized Official

Name: MR. DONALD LEE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: MS
Phone: 402-734-5275