Healthcare Provider Details

I. General information

NPI: 1710174107
Provider Name (Legal Business Name): NORTHWEST CENTER FOR BEHAVIORAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 12/08/2023
Certification Date: 12/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193461 E CT RD 304
FORT SUPPLY OK
73841-0001
US

IV. Provider business mailing address

PO BOX 1
FORT SUPPLY OK
73841-0001
US

V. Phone/Fax

Practice location:
  • Phone: 580-766-2311
  • Fax: 580-766-2316
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License Number44-2593
License Number StateOK

VIII. Authorized Official

Name: CHRISTEN SCHMIDT
Title or Position: DIRECTOR OF PHARMACY
Credential: DPH
Phone: 580-766-2311