MEDICARE: CHICKASAW NATION DIVISION OF HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy
2	332800000X	Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy	235613	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	2076080	OTHER		PK

General Provider Information

NPI Number	:	1487715587
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHICKASAW NATION DIVISION OF HEALTH

Provider Business Mailing Address
First Line	:	933 N COUNTRY CLUB RD
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2845
Country	:	US
Telephone Number	:	580-272-5710
Fax Number	:	580-272-5711

Provider Business Practice Location Address
First Line	:	933 N COUNTRY CLUB RD
Second Line	:
City	:	ADA
State	:	OK
Zip	:	74820-2845
Country	:	US
Telephone Number	:	580-272-5710
Fax Number	:	580-272-5711

Authorized Official
Title or Position	:	PHARMACIST
Name	:	ZACH WILLIAMS
Credential	:	RPH
Telephone Number	:	580-272-5710

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	03/09/2016

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