| Full Name | |
|---|---|
| Speciality | Indian Health Service/tribal/urban Indian Health (i/t/u) Pharmacy |
| Location | 109 Kerr Ave, Poteau, Oklahoma |
| Authorized Official Name and Position | Teresa K Jackson (ADMINISTRATOR) |
| Authorized Official Contact | 9185677000 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
109 Kerr Ave Poteau OK 74953-5270 Ph: (918) 567-7096 | 109 Kerr Ave Poteau OK 74953-5270 Ph: (918) 567-7096 |
| NPI Number | 1851448526 |
|---|---|
| Provider Enumeration Date | 01/04/2007 |
| Last Update Date | 05/07/2013 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1851448526 | NPI | - | NPPES |
| 100244980B | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261Q00000X | Clinic/center | 19-3887 (Oklahoma) | Secondary |
| 332800000X | Indian Health Service/tribal/urban Indian Health (i/t/u) Pharmacy | 19-5161 (Oklahoma) | Primary |
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