Healthcare Provider Details

I. General information

NPI: 1225703077
Provider Name (Legal Business Name): PAUL CHUCHONG VAHCHUAMA PHARM.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2021
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19600 E ROSS ST
TAHLEQUAH OK
74464-0545
US

IV. Provider business mailing address

11523 E 17TH PL
TULSA OK
74128-5615
US

V. Phone/Fax

Practice location:
  • Phone: 539-234-1100
  • Fax:
Mailing address:
  • Phone: 479-847-5437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number70069
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19248
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: