Healthcare Provider Details

I. General information

NPI: 1346623584
Provider Name (Legal Business Name): CHEROKEE NATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

V. Phone/Fax

Practice location:
  • Phone: 918-772-4754
  • Fax: 918-458-1211
Mailing address:
  • Phone: 918-772-4754
  • Fax: 918-458-1211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number367330
License Number StateOK

VII. Legacy identifiers

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

# 1
Identifier2152457
Identifier TypeOTHER
Identifier State
Identifier IssuerPK

VIII. Authorized Official

Name: STACEY THORNTON
Title or Position: PHARMACY STUDENT PROGRAM COORD
Credential:
Phone: 918-458-3207